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One in three midwives are willing and able to work in a 'continuity based model'

One in three midwives are willing and able to work in a planned new system aimed at women having the same midwife throughout pregnancy, labour and birth, according to a University of Birmingham survey.

31 May 2018

The survey comes as the Government recently set out plans for expectant mothers to be cared for by the same midwives throughout their pregnancy, birth, and postnatal period in a ‘continuity of carer’ midwifery model. NHS England said research suggested women who used this model were 19% less likely to miscarry, and 24% less likely to give birth prematurely.

The plans follow the 2016 National Maternity Review, ‘Better Births’, which recommended that “by 2021 every woman should have a midwife, who is part of a small team of four to six midwives, based in the community who know the woman and family and can provide continuity throughout the pregnancy, birth and postnatally”.

To explore midwives’ perspectives of different ways of working, and to inform the implementation process, researchers at the University of Birmingham conducted an online survey of midwives from seven of the 44 Local Maternity Systems across England that are tasked with implementing the ‘Better Births’ recommendations.

The survey, conducted in October 2017, has now been published by the University in a report, ‘Better Births and Continuity: Midwife Survey Results’, with the research being funded by the National Institute for Health Research West Midlands Collaboration for Leadership in Applied Health Research and Care.

Of the 798 midwives who responded to the survey, around a third (35%) were willing and able to work in a 'continuity-based' model of care that included following the women they care for in both community and hospital, through pregnancy, labour, birth, and the postnatal period. Around half (53%) of midwives were willing to work in models where they provided continuity in the community only, with different midwives providing care for hospital births.
Half (50%) of the midwives reported being confident to attend a home birth as the primary carer, while 59% of midwives reported that they needed to update their clinical skills to work across settings, as would be required in the ‘continuity of carer’ system.
Meanwhile, 41% of midwives stated that they were unable to work a different pattern to their current role, and 53% of midwives reported that they did not have the clinical confidence to work across settings, with 19% not confident to work in hospital labour wards.

The planned changes are significant, particularly for care during labour and birth, as most midwives currently work in either the community or a hospital and do not follow women through the system. Continuity models of care also generally require more flexibility in midwives’ availability, so that they can be there when a woman needs care.

In this survey, many midwives suggested that they would find it difficult to work flexibly and that they needed predictable working patterns due to childcare, health issues, a desire for work-life balance, and reducing work intensity as they approached retirement. Two thirds of those surveyed had child or adult caring responsibilities, and half worked part time. Just over a third stated that they were not currently able to work at night, a time when many babies are born.

Lead researcher Dr Beck Taylor, Clinical Research Fellow and Honorary Consultant in Public Health, of the University of Birmingham’s Institute of Applied Health Research, said: “While the principle of continuity was welcomed, many midwives in our survey told us that they would face significant challenges in changing the way they work.

“Half were concerned that they did not currently have the skills to work safely across both hospital and community, and some stated that being a 'jack of all trades' working across all settings was not a good idea.

“Our survey suggests that the greatest challenge will be to provide continuity of midwife during labour and birth: babies arrive when they are ready, not when 'their' midwife is available.

“At a time when there is a national shortage of midwives, and many are leaving the profession, it is essential that frontline staff are willing and able to adopt new care models.”

Professor Christine MacArthur, also of the Institute for Applied Health Research, said: “It is essential that NHS England and Local Maternity Systems listen to and address midwives’ concerns about the changes, evaluate the safety of midwives working across settings at scale, and evaluate the impact of the changes on midwives.

“In order to succeed, midwives will need to support the plans. Midwives will also need support to change, and to sustain new ways of working while maintaining their own well-being.

“It is crucial that midwives are able to accommodate new ways of working if the policy aim is to be achieved.”

The University of Birmingham report lists 16 recommendations aimed at policymakers, NHS leaders, and midwives.

Fiona Cross-Sudworth, Research Associate at the University of Birmingham and a registered midwife, said: “While the aim for the majority of women to receive continuity of care by 2021 is laudable, we suggest that achieving majority continuity within three years, with the current workforce, will be extremely challenging.

“To improve outcomes for women and babies within the current workforce constraints, we recommend that continuity across pregnancy, labour, birth, and beyond is prioritised for women with the greatest clinical and social need, while at the same time working to strengthen continuity of pregnancy and postnatal care for all women.”

The survey found that barriers to changing the way midwives work, included caring responsibilities (64% had caring responsibilities, 46% for children), transport issues, commitments elsewhere (e.g., other midwifery roles, volunteering), health conditions, well-being and work-life balance concerns, personal preference for particular ways of working, and quality of care and safety concerns.

The survey found that what would help midwives to work differently would include concessions in how midwife roles are organised, adequate staffing to cover the work, financial/practical incentives, induction, support, training, and development, good leadership, management and organisation, continuity and quality as an incentive, and a change in midwifery culture.