Julia Cumberlege talks about choice, safety and continuity of carer
When Changing Childbirth was published in 1993 there was little research concerning maternity services compared with today. We should be so grateful to the NPEU and other research centres who have found this an interesting and productive area. We are indebted to all those academics, research midwives and obstetricians who have provided us with robust evidence on many aspects of maternity care. They have worked tirelessly to provide us with the credible information we need, not least concerning continuity of the health professional looking after a woman and her baby(ies).
So much has changed in 25 years regarding society, the advances in conception with IVF a possible choice, the age of mothers giving birth, the condition of their health, the management of labour and the newborn, and so on. Nevertheless some things are so fundamental that they should not be cast aside as being old fashioned and no longer relevant. One such is the relationship and trust between the health professional and the woman. Better Births, the most recent review of the future shape of maternity services in England, published in March this year, has not revisited Changing Childbirth since it is in the past and we must go forward. However, continuity of carer is one of those fundamentals that has emerged again and this time we have not only the obvious presumption that it provides safer care and enhances the woman and her partner's experience, but we have the evidence to prove it.
Throughout the extensive public engagement we undertook, women and their families told us they wanted to know the health professional, usually the midwife, who cared and advised them throughout their antenatal period, the birth and post-natal care. Continuity of carer was a major factor in ensuring they had a good experience. This is not rocket science. Surely it is obvious that in one of the most challenging experiences she will undergo she will want continuity of carer to help reduce any potential trauma. Relationships are crucial and not only for the woman and her family but for those professionals looking after her.
One woman told me she had encountered 42 people throughout the months before, during and after the birth. Others have told me how they were so weary at having to give the same information time and time again wasting everybody's time. The most poignant was the person who told me when asked how her first baby, born two years ago, was thriving now as a toddler, had to explain to so many different people that her baby had died soon after birth. She dreaded this inevitable conversation as she knew her notes would not have been read. Reading notes and sharing information is essential to ensure that women have a better experience and a safer birth. Women and midwives told us the notes are now so comprehensive, (and there is a question about if they really need to be so long and deep) that midwives who are busy have not got the time to read them before they see the woman. To this end one of our recommendations in Better Births is to introduce electronic records to be held by the woman and shared among professionals, with her permission. The childbearing generation of today are increasingly savvy and competent with new technology, many will tell you they have their lives on their smartphone and are amazed that the NHS is still in the last century. In the Models of Care Workstream Soo Downe told the review team that prematurity is on the rise and millions of pounds are being spent on research to reduce it, but we already have a solution – continuity of care reduces prematurity by over 20%.
Jane Sandall et al 2016 in their research1, which was published in January this year, identified 15 studies involving 17,674 mothers and babies. It included women at low risk of complications as well as women at increased risk, but not currently experiencing problems. All the trials involved professionally qualified midwives and reliable methods were used to assess the quality of the evidence (no trials offered models of care that offered home birth). It showed fewer women had an episiotomy or instrumental birth when they had continuity of carer. Women's chances of a spontaneous vaginal birth were also increased and there was no difference in the number of caesarean births. Women were less likely to experience preterm birth, and they were also at a lower risk of losing their babies.
So we know the value of continuity and that it is a type of care women would choose if it was generally available on the NHS; so far so good. But the crunch issue is not the 'what' and the 'why' but the 'how'?
Twelve hour shifts are the norm, but they are not sacrosanct, indeed they are a relatively recent development. We only have to look to Holland to see the success in community nursing of self-organising community nursing teams, where long shifts are long forgotten.
The Buurtzorg system of Neighbourhood Care is truly impressive. It was started in 2007 with one team of four nurses. Today they have 9,500 nurses working in 850 independent teams with 45 staff in the back office (Chief Executives eat your heart out) with two Directors and 16 coaches. The coaches are important as they will advise and help those teams which have relationship problems within the team. The nurses care for 70,000 patients using electronic tablets in the patient’s home. Writing up the record of the visit takes around 20 minutes and the notes are agreed by the patient. Clinical problems are
referred to the appropriate clinical professional quickly and efficiently. Patient satisfaction scores are 30% above the average for traditional community nursing.
On our visit and quoted by others, is the power of the autonomy the nurses enjoy. They have the freedom to always put the patient at the very centre of care without top down direction or inappropriate management systems. They organise their diaries to fit with their lives and their patient’s needs. Burnout is a myth. Recruitment is not a problem and sickness rates among the nurses have fallen by one third.
Of course maternity services are different from community nursing and Holland is not England but surely there are some good lessons to be learnt?
Not for a minute do I think continuity of carer is easy or can be done overnight, since it requires a complete rethink of the way we organise current services. Neither do I think it is too difficult or can be left on the backburner. I know there are some remarkable midwife leaders in our service and this is a call to them. I also know there are midwives who are leaving the profession, disillusioned and sad to be leaving a service for which they trained and loved. In addition there are well-trained young midwives or those in training who cannot believe the way they are being treated. The phrase I hear too often is ‘I love the work – I hate the job’.
With labour wards working at, or even above, 100% capacity, with more difficult births, with many staff who are giving up and others who grit their teeth, knowing they have to keep going in a service that is unsustainable, we have to think differently, be creative and use imagination.
The two major themes running throughout Better Births are choice and safety. Continuity of carer is essential to achieve these twin goals, if we are to achieve safer and better births with the woman, her baby and her family at the centre of care.
With such compelling evidence continuity must be implemented to provide a safer service giving satisfaction to women and midwives alike.
National Maternity Review
1. 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 2016. Issue 4 Art
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