Transforming to Continuity of Midwifery Carer - Exciting Times for Northern Ireland Maternity Services

AIMS Journal, 2023, Vol 35, No 1

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By Leslie Altic

Since the publication of Changing Childbirth^[1] and Better Births^[2] , UK maternity services have slowly been moving towards implementing Continuity of Midwifery Carer (CoMC). This model can be described as one where women receive consistent care from the same midwife or a small team of midwives throughout their pregnancy, birth and the early postnatal period, enabling the development of respectful and trusting relationships between midwives and the families that they care for. AIMS continues to campaign for this transformation to maternity services across the UK.^[3]

The current maternity service model means that women receive care from different midwives depending on the stage of pregnancy, risk factors, where they live and what local services are available. With over-stretched staffing and resource issues continually challenging the system, the women who speak to me often report an experience of maternity care that is disjointed, rushed and impersonal. This frequently leaves women feeling as if they are just another number, unprepared for birth or not knowing who to turn to with questions or concerns. As someone who feels lucky to have received continuous care through each pregnancy, it was extremely reassuring and very personal to have built a relationship with my caregiver; I felt safe and supported by someone who knew me and my family.

By facilitating truly individualised care, the CoMC model of care leads to better clinical outcomes for women and their babies as well as a more positive experience.^[4],[5] Research has shown that women are less likely to experience stillbirth and pre-term birth, less likely to experience induction or interventions and more likely to have a spontaneous vaginal birth. Evidence also indicates that midwives may benefit from working within this model, experiencing greater professional satisfaction and more autonomy, with less anxiety and burn-out^{[6] [7]} .

CoMC has been embedded in the Nursing and Midwifery Council standards and all midwifery students must now learn and work in this model during their studies. In Northern Ireland, caseload midwifery had been an option for women but was not the standard model of care and was phased out about a decade ago. With the caseload model, women received continuity before and after the birth, but were still unlikely to be supported by a midwife they knew in labour. Of the five Trusts in Northern Ireland, the Northern Trust piloted a continuity of carer scheme called the Lotus Team,^[8] and the Southern Trust launched the Birth at Home team^[9], which follows the principle of the continuity model for women that are planning home births. Both teams have received extremely positive feedback from women who have used the service^{8, [10]}.

In 2022, Emma received care from the Birth at Home team in the Southern Trust:

“I first heard from the team by phone call shortly after my 12 week booking appointment. From this call onwards all of my appointments were with the small team of midwives in my own home. As they are a small team, communication was excellent. I didn’t feel like I had to explain or repeat myself every visit. I was able to contact the team if I had any concerns and speak to someone I already knew, and who knew me. It was very reassuring. Coming up to the birth, I knew that it would be a familiar face walking through the door when I was in labour. Having the same midwife for labour who had met me at 16 weeks and multiple other visits gave me a sense of instant comfort, which I fully believe helped the labour process. Overall, it was an incredibly positive experience.”^[11]

To date, though, the CoMC model has not been fully implemented across Northern Ireland, and so in 2021, a regional group ranging from midwives and doctors to service users was set-up to begin the move towards transforming maternity care here. As it will involve significant reform and a fundamental cultural shift from the current model, it is being rolled-out in a phased approach. One of the issues at the centre of the planning is an awareness that some previous attempts at CoMC and caseload models in the UK have led to higher levels of burnout in the midwives working within the model^[12]. Doing it in this slow and steady way means that as well as learning from previous experience in Northern Ireland and successful schemes across the UK, we can manage and adapt to any issues encountered by the first local teams. This should mean that when the model has been fully implemented it will run smoothly and sustainably. Taking a regional approach also means that CoMC will be available and work in the same way across the country; there will be no postcode lottery.

Teams will be made up of a small number of midwives, a maternity support worker and a linked obstetrician, thus it is an integrated approach to maternity services. As the roll-out continues, student midwives will also have the opportunity to work in this model during their training. Teams will run on a mixed-risk caseload, covering both women having straightforward and complex pregnancies, and be geographically based (as large portions of Northern Ireland are quite rural) and midwives will support their choice of birth place. At the booking appointment, the woman will meet her named midwife who will be responsible for coordinating her care and aim to see her for all appointments; these can be flexible and arranged to suit both the midwife and the woman. Should there be a need for clinical referral to additional support services, the woman’s named midwife will attend these appointments with her to ensure continuity. This can be especially beneficial for women who have more complex pregnancies or support needs as they often will not see a midwife while under consultant-led care.

Phase 1, the organisational structure and development of the regional model for Northern Ireland has been completed and we are now entering Phase 2, the initial small-scale program of the first two teams in each Trust. Each Trust has a local implementation group headed up by the Trust’s CoMC lead midwife which looks at how the teams can be rolled out to meet the needs of the local population. The first CoMC teams will prioritise those who are at increased risk of poorer outcomes, such as those living in areas of greatest social deprivation, smokers, Black, Asian and mixed ethnicity groups, and women aged 20 years and younger, then the scope will widen as new teams are added. The aim is that at full implementation, CoMC will become the standard model of maternity care in Northern Ireland and the majority of women will be able to benefit.

At each level and phase of the program, a number of key stakeholder groups are involved, from midwives and student midwives, to maternity support workers and obstetricians and especially service user representatives. This ensures that the model is co-designed and co-produced from the outset so that it meets the needs of all those working within the model as well as the women and families they support. As a service user representative with many years of involvement in the improvement of maternity services, I have been part of the implementation plan right from the start and am a member of the regional group as well as my local Trust group. It is vital to bring the service user voice at every level in the development of this model so that it can be designed with their experience at the forefront.

The first teams will launch in April 2023, with the second teams to follow shortly after that. There will be challenges along the way, but with initial feedback from service users who are very excited about the change, the commitment of amazing midwives who are keen to work within this model, and the widespread involvement of other groups in this transformation, there are exciting times ahead for expectant parents in Northern Ireland.

Author Bio: Leslie Altic is a birth and postnatal doula and hypnobirthing teacher based in Belfast. For more than 8 years she has been involved with shaping maternity services in Northern Ireland through local Maternity Service Liaison Committees, regional policy working groups and campaigning charities. Leslie is also a member of the AIMS Birth Information Team.