As a midwife I thought I knew all about continuity of care.
I trained in the heady days following the publication of Changing Childbirth. Dept of Health 1993. This introduced the concept of the three C’s, choice, continuity and control. At the time, numerous caseloading groups were set up to offer continuity. One midwife carrying a caseload of women for whom she is responsible. She plans and manages their care, is on call to them and together with a back up midwife and with access to specialist referrals she provides all the midwifery care. This was seen as the gold standard of midwifery care where a close trusting relationship could develop and all the evidence demonstrated improved outcomes for mother and baby as well as greater satisfaction for women and midwife.
So how is it that more than two decades on we are still chasing this elusive continuity?
Part of the problem is that this style of care was grafted on to an established and well entrenched maternity services which is hospital based and where buildings are staffed rather than women. Midwives get used to working regular long shifts and only cope by focusing on their off duty. So how does a caseload team fit?
What happened (and still does) is that said midwife has a busy time with her women giving birth, she is called out frequently and then does all the immediate intensive postnatal visits, then, whenshe ought to be able to take a breath and catch up, the midwifery managers say that the delivery suite or antenatal clinic is short staffed so she needs to go in and cover because “she is not busy…” Result? Midwives get burned out and return to the predictable if less satisfying traditional shift work. Another problem is that caseloads get bigger and bigger in an effort to be more cost effective but again the result is counter productive as quality of care suffers and again midwives leave. Everybody concludes that caseloading doesn’t work and/or midwives don’t like to work in this way.
Maybe midwives do find it too difficult but having worked this way for nearly two decades I am very clear that having a trusted buddy and the back up of colleagues makes a huge difference. A manageable caseload helps and knowing can have the odd evening off call or go to the theatre knowing my mate has the phone. Planned weekends and holidays are also organised in the same way.
Currently Trusts and Hospitals are trying a new approach, a sort of watered down version of continuity offering team caseload midwifery where the woman might see any one of 6 midwives, or aiming for continuity in the ante natal period only. Surely there is another way where women and midwives can work together. Midwives being given freedom to manage their caseload with the support of one or two other midwives who the woman knows. Women knowing they can develop a close trusting relaionship with their midwife and that she is there for them.
What everybody forgets is that if we work around the woman and allow the midwives to manage their own time and caseload it is manageable. But will it ever be possible within the current system of ‘super units” the big complex maternity units where volume is the key rather than individuality? Or do we need to set these caseloading teams up outside of the main units in the community.
Buurtzorg Nederland http://buurtzorgusa.org/about.html operates a community nurse service just like this and is massively successful. Neighbourhood Midwives has the same vision and while we currently offer a private service throughout London and the South East our social mission is to offer NHS services with just this model.
What do you think about Continuity, what is it and does it matter?
Read our other articles and blogs appearing through August on this topic.