How do you feel about continuity of care in midwifery

[RosieLemonade]

Sorry if my title is a little clunky. I saw my 2nd midwife this pregnancy a few weeks ago (16 week appointment). She told me this was the last time she would see me as they were switching to a continuity plan and she was moving to another pratice. She said I would have 8 midwives in a team and one of them would be there for delivery. I would rather have one midwife the whole way through and then a stranger deliver the baby. I had severe mental health issues during my first pregnancy and feel consistentancy would help with them! Also I had to explain this to both midwives and tell the second one I was consultant led as she didn't even know! I've also read midwives are not happy about the changes. What are your thoughts and experiences?

I don't think they ever guarantee you'll have your named midwife at your delivery. my understanding is that they are there to ask questions during the pregnancy and will try and be there at delivery but also do home visits etc so depends where they are on the day.

I'm 25 weeks and haven't even met my midwife yet!

If you can afford it maybe consider hiring a private midwife to help you during the labour (this may be harder if your hospital only allows one birthing partner) but its worth looking into

With our first, we had a community midwife who did all the antenatal appointments/checks then a different midwife for delivery of our boy. Post delivery it was our community midwife who came out to the house

I think it's normal to have a different midwife for delivery (depending on where you give birth... centre/hospital)

Yes, I read about this previously. I think it was something to do with getting community-based midwives back into hospital for actual deliveries on a rotation, etc. instead of being purely community based?

Personally I am like you - I'd prefer the same face all the way through for my community appointments and then a stranger for birth, as if there's a rotation of 8 community midwives then the one at birth will be pretty much a stranger anyway as you don't have many more appointments than that anyway.

With DC1, it was the same midwife all the way through for the community-based stuff but I'm not sure if they've changed it now.

I had one midwife in community and then different midwives in hospital (all mine end up being delivered by obstetricians in theatre).

The local hospital did go into special measures a few years ago and midwifery/maternity was particularly criticised. They tried a model of small group of midwives for both care in community and birth. The idea being to have more continuity of care. Each small group would be responsible for x number of women.

I don’t think it worked though and think they are back to much more midwife in community and whoever is available when you rock up to hospital.

Just to add, it can be difficult to have the same midwife right through as you may give birth at 2am and they are on another job or not working etc. Maybe a bit different for a home birth?

I think there was some backlash about switching to this model because it meant that some of midwives who had been working only community hours (so Mon-Friday, 9-5) and for quite some time would suddenly be put on a rota to do hospital shifts, which would obviously have quite big implications re: childcare, commuting, and other things.

In our area, it was the other way, where hospital-based midwives would sometimes cover in the community when there were absences and holidays, but community midwives weren't rostered to do hospital shifts - they were purely based at the local health centre and did post natal visits, nothing to do with labour.

There's some interesting discussion on it here. www.britishjournalofmidwifery.com/content/other/what-midwives-think-of-the-continuity-of-carer-model

I think the skills and training aspect is quite interesting.

I had antenatal appointments and postnatal visits with a team of 4-5, and probably saw each one twice. Hospital midwives were a different team entirely.

I’m a midwife. These changes are apparently because women want them. They want a midwife at delivery who they have met in pregnancy and as a result community midwives now need to rotate which means they won’t be as available to work in community. None of us are happy with the new system and it doesn’t work at all yet we are told women prefer it this way. I am very sceptical of that.

I've had a different midwife for every appointment except the last 2 appointments which were the same midwife.

I just assumed when you go into labour you just get whoever is working?

I’ve just assumed you get who is working and available. I’m consultant led. Never saw my actual consultant once with my last birth - saw someone different every appointment and then a new midwife at delivery. This time around I’ve seen my consultant once and someone different every other appointment. Has been fine. As was having a midwife I’d never met deliver the baby. Maybe as I had no expectation that it would be the same person responsible throughout - however, I think from a practical point of view it’s more u likely that one midwife could look after the care and delivery throughout due to holidays, sickness, timing of Labour etc.
Hopefully find the journey a good one anyway and goodluck with it all

I will have the same midwife for all of my antenatal appointments. She’s lovely, and it’s been really nice getting to know each other. It will be an unknown midwife at the hospital when I have the baby. My original midwife will then come and visit us at home.

I can’t imagine a better system than the one I am currently experiencing

I've experienced this for my most recent pregnancy. It was excellent. I saw one midwife for my antenatal appointments and post partum. I had a different midwife on the same team deliver my baby as the midwife I saw regularly wasn't working that day - I think to be able to guarantee the same midwife throughout would be logistically impossible. In my first pregnancy I saw a different midwife at every appointment and having experienced both having continuity was so much better. I was able to get to know my community midwife, she was so readily accessible and she was able to work through my worries and help me feel empowered when it came to giving birth.

That being said, it's not just about me as a patient. The rota for the midwives sounded absolutely brutal and an entirely unsustainable way of working. It seems to be a lovely idea but impractical with the staffing, resources and funding that NHS services have available to them. It might work for the patients, but not for the staff.

@Madwife123

I’m a midwife. These changes are apparently because women want them. They want a midwife at delivery who they have met in pregnancy and as a result community midwives now need to rotate which means they won’t be as available to work in community. None of us are happy with the new system and it doesn’t work at all yet we are told women prefer it this way. I am very sceptical of that.

This is interesting.

I'm in my second pregnancy.

For my first I had the same community midwife throughout, and then in labour I just had however was available.

This pregnancy I'm seeing different midwifes every appointment. As I've only seen each of these midwifes for 15 minutes each, it really wouldn't make a difference if it's one of them or someone completely different when I go into labour.

What would have made a difference, after a traumatic first birth, is being allowed a doula at the birth with me. But our trust has current banned them because of Covid.

That's the opposite of what OP is going to be getting though under this apparent continuity of care model though isn't it? The 'continuity' seems to be that it's a fixed team but not necessarily a fixed individual, unlike OP's first pregnancy. The 'continuity' aspect is presumably that one of the fixed team will be on duty at the hospital when she goes into labour, but it's hard to see how that's really continuity of care if she's only had one or two appointments with them antenatally. It's not really enough to feel like you've got any kind of bond with them.

My pregnancy wasn't under continuity of care model but I had continuity of care as I see it because there were two fixed community midwives for my area and you saw the same one each time unless she was on holiday. I saw my midwife for all my antenatal and postnatal visits bar one as it was the weekend. But hospital was midwives I'd never met.

I do think that true continuity of care model is that you see one midwife as much as possible, but it seems like logistically, health boards are struggling to implement it with the additional issue of having the midwives on call and doing hospital shifts, and that's why you end up seeing lots of different midwives under the banner of the same 'team' because it's just unfeasible for many places to implement properly.

Yep as @SylvanasWindrunner says. One midwife is impossible as it will mean 24/7 on call for labour so it’s the team. IMO you get LESS continuity under the new system as while you might get a labour midwife you’ve met once for 15 mins you will see loads of midwives throughout pregnancy. Previously you would have seen 1 or 2 as they were not required to also cover labour ward and so the teams were smaller.

Sounds like one of of those things that sounds good on paper but everyone who is actually doing the work on the ground knows is totally unworkable.

I had my children with a caseloading midwife team and had real continuity of care; one of the midwives saw me during all my pregnancies and delivered two of my children for example. I can't relate, thankfully, to some of the horror stories I read around lots of different midwives, not being heard, lack of support during labour etc. I was so lucky, and I'd want the same for everyone. This sounds like it was originally conceived to provide something like that.

The different was though that the midwives working in the team (and some changed inevitably through the years) were all proactively making the choice to be in that team; the working hours were challenging and some had left because of family commitments and the need for more regular hours for example. They all also embraced a very similar ethos so it didn't hugely matter if the midwife on duty for the birth wasn't one you knew so well (although they made sure you'd met the whole team at least once if possible) as you knew they would take the same approach. It doesn't sound like those things will apply here, so you'll have lost some of the value added in the model.

When it works, it's amazing.

Personally having given birth during covid I would have preferred a midwife who did her job and wasn't negligent during my labour.

My community midwives were brilliant but the hospital ones shocking to the point of confirmed medical negligence. I would have far far preferred to have one from the community team as they all listened to me and my body rather having this 'I know best. I have read statistics and textbooks' attitudes which the hospital based one's had.

I cam defiantly see an argument for community midwives to sometimes go into hospital for births and hospital midwives to go out to community care (that may already happened under CPD)

I'm a community midwife so I see women for all antenatal and postnatal checks but the hospital midwife will deliver them. I'm in a team of 7 and we try to see our own women but if they need an essential check and it's our day off one of my colleagues will visit.

Continuity involves teams of 8 midwives who provide the above but also deliver the woman. The idea is that your actual named midwife delivers you but the reality is that as long as it's one of the team it is chalked up as a continuity birth/success/statistic when it's no different to the usual community model.

I'd say 99% of staff are against it. It's not a workable system and it's a huge drain on resources.

The supporters of it claim it doesn't need more staff to run it but this is blatantly false. For example, a community team of 4 midwives caring for 500 women per year were moved to continuity. This required 16 midwives to look after those 500 women. The hospital couldn't find 16 midwives so they took 3 of that existing team, 5 midwives pulled out of the hospital and they took half of the caseload of 250 women. The remaining 250 were left to the remaining community midwife and another community team were drafted in to help with overspill.

Staff are run in to the ground and I feel sorry for the women.

I supposedly had continuity of care. I never saw the same midwife twice in my entire pregnancy.

Continuity of Carer is a way of care with proven benefits. Reduced intervention rates, reduced chance of premature birth. Lower stillbirth rates. Increased choice and satisfaction. A team of 6-8 midwives will work closely and each midwife will have a manageable caseload and will cover all care.
There are specific requirements and measures as the what continuity actually is.

A woman should have a named midwife that does at least 70% of her care and a woman should see no more than 3 separate midwives for routine and intrapartum care and she should know the midwife at her birth. In reality this usually means the named midwife does all routine appointments. A woman may see another midwife if her named midwife is on leave. For births the team will usually work on a rota system because to actually be available 24/7 is impossible. You may only meet the rest of the team at parent Ed sessions or meet the team events. After your birth you will again see your named midwife plus one of the others you have already met if needed.

If the model is followed it works. Midwives plan and control their own work as and when they want to as long as it gets done. It’s flexible and can fit in totally with home and other commitments. Madwife123 does not speak for all midwives when she states ‘none of us are happy with it’. Once midwives are given the chance to practice effectively and autonomously they understand the benefits and plenty of us prefer this way of working. However there are numerous issues.

There is a national shortage of midwives and this is a huge transformational change that has had no additional funding.
Some areas tick a box and say they are providing it but seeing a different midwife each appointment and an unknown midwife at birth is not continuity and will not have the same outcomes.
Many midwives have got used to working in a specific area and do not want to work across areas. Many midwives cannot commit to being available over night. Many midwives are so utterly exhausted by the broken system they cannot face giving anything extra to yet another change.
when it’s done properly it works for both women and midwives but without national funding and whole scale change different areas will do different things and women will get a patchy service.

My DD is 4months old and we experienced the continuity of care model. There was a team of 8 midwives and i was assigned 2 for all my antenatal appointments. It was really nice as i felt like i got to know them both really well and definitely felt like i didn't have to explain myself fresh every time i had an appt.

For the delivery, i had a midwife who was unknown to me, but one of my named midwives had been on the antenatal ward when i was admitted and one was on the postnatal ward after i had my baby, which was really lovely. My baby was poorly and spent two weeks in NICU /SCBU and i got lovely messages from the midwives that i will treasure.

So for us, it really worked and i would def hope its the same for if i have another baby. However, there was another thread recently where lots of midwives were talking about how much they dislike the continuity of care model and that it doesn't work in terms of working practices, which is a real shame.

I should add that the midwife at my delivery was on the team of 8, i just hadn't met her before delivery.