Midwifery in rural areas: a Welsh adventure

By Alice Sorby, RCM Employment Relations Advisor and Lia Brigante, Quality & Standards Advisor on 03 September 2019 Maternity Services NHS Wales RCM Wales

Following the publication of the Welsh Maternity Services strategy Employment Relations Advisor Alice Sorby and Quality and Standards Advisor Lia Brigante found themselves enjoying a scenic train journey to Welshpool to visit midwives in Powys to learn more about how they work and how continuity of care can work in the area.

They were invited by the Head of Midwifery and former chair of the RCM Board Julie Richards to run a workshop on how to implement continuity across the whole pathway and spend some time with the teams. Here is what they had to say about the trip:

Powys is a large rural Health Board, it covers a quarter of the land mass of Wales! Powys Midwives provide a flexible 24 hour on call service to meet the needs of the clinical activity rather than permanent staffing the buildings. There are six Birth Centres (FMUs) – Welshpool, Newtown, Llanidloes (North Powys) and Ithon (Llandrindod Wells), Knighton (Glyndwr) and Brecon who would be staffed once low risk women commence intrapartum care. Ithon and Glyndwr teams are currently piloting Continuity of Care schemes. Ithon Birth Centre and Newtown Birth Centre host the recently developed Midwife Led Sonography service and Day assessment services. During 9-5, there will be core midwives working across the county providing antenatal bookings, antenatal appointments, 36 week birth discussions, antenatal education and postnatal community visits. Some of the antenatal contacts are offered through birth centre but majority have appointments in their home.

On our first day in Powys we had the pleasure of shadowing the brilliant midwives. Lia the RCM’s Quality and Standards Advisor, also a case load midwife and Alice, Employment Relations Advisor, (not a midwife!) split up and shadowed teams in Newtown and Welshpool. We had lots to catch up on after experiencing a day in the life of a Powys midwife!

LB: So Alice this was your first experience of a day in the life as a midwife in the community, and you probably had a unique experience of midwifery-led care in a rural area. Was it as you expected?

AS: I felt very privileged to be involved in conversations the midwives had with women and the trust that was built up through lasting relationships. For example women having their second and third babies with the team and even same midwife. As a case load midwife in London Lia was this your experience too?

LB: At first I was struck by the long miles and huge catchment area that the midwives cover with on-calls in Powys but driving in London when there is traffic can actually involve the same time commitment but with very different mileage. I was very impressed by the fact that midwives are doing so much for example preconception and scanning which means that the women only go to the MLU to receive their care.  The reduced case load size, due to the geographic distances, enables midwives to spend the amount of time with women that we all midwives wish they had!

One example was that while visiting the MLUs one of the midwives that was on call at the weekend told James that one of his postnatal women had called and was very upset. James was able to shuffle his diary to arrange to visit the woman to provide the emotional support that she needed, accommodating a visit and dedicating her a good hour. Did you see anything similar at the MLU?

AS: The midwives I was working with were all trained to use aromatherapy as part of expectant management and were routinely offering foot massages with acupressure points and essential oils to women, although this was a relatively new offer they were already seeing great results. Overall as a complete newbie to community midwifery I couldn’t believe how varied a role it is and how important working as a team to ensure the women and babies in the area are safe and satisfied with their care. The rural nature of the service meant that the community really understand and value the role of the midwife. The receptionist at the hotel we stayed knew all about the midwives and spoke about her daughter’s recent experience being cared for by them!

LB: Absolutely. I loved how community centred the care was with many homebirths and MLU births. James, the community midwife, took me around for home and MLU visits. The women were familiar with birthing rooms on MLUs as part of their antenatal care takes place there. I think using MLUs as a proper community hub is very sensible and it contributes to sustainability of midwifery-led units. I did struggle a bit when women started discussing details of harvesting with James, who’s also a part time smallholder on top of being a great midwife!!

Our last day in Powys we held a workshop with midwives and midwifery managers to  looking at working patterns for the service as part of the update of the Operational Policy and explore the nuts and bolts need for supporting Midwifery continuity of care in Powys. The way the midwives work currently, with continuity across antenatal and postnatal care meant their service had great starting point. Lia was able to share her experience working in a continuity model and the evidence of the benefits for both women, babies and in her team the midwives as well. Alice spoke about the working lives of midwives, ensuring that the terms and conditions set out in the Agenda for Change handbook are adhered to, but also taking the opportunity to improve the work/life balance of staff through self-rostering and managing working time and patterns as a team.

Another thing that struck us was the forward planning, our visit and workshop was just two days after the all Wales vision was published and Powys were already planning how to embed the vision in their service!

Julie Richards, Head of Midwifery and Sexual Health at Powys Teaching Health Board/ Bwrdd Iechyd Addysgu Powys said: "Powys Midwifery Management and Leadership team were delighted to have the knowledge, skills and expertise of the RCM in facilitating discussions around working patterns for the Powys Maternity services. Everyone enjoyed the interaction of the visits and workshops to help explore the core components and Nuts and Bolts we need to think for Powys services as we plan for the implementation of the all Wales Maternity vision."