Midwifery Continuity of Carer - the clashing of truths
Here is the first truth.
There is no doubt that women, when asked, say that they would like to know their midwife throughout their maternity journey. There is also no doubt that some midwives like to work in this way - and indeed describe it as the most fulfilling way to work as a midwife. There is good evidence that supports the benefits of Midwifery Continuity of Carer (MCoC) across antenatal, intrapartum and postnatal care. And there is also evidence that outcomes and experience are improved when healthcare generally is delivered by the same person or team. Many people passionately believe that a wholescale implementation of MCoC will be the panacea for gold standard maternity care. It is true we would all want that gold standard and would want to support this ambition.
Here is the second truth.
Policymakers in England in their quest for improvement and safer care in maternity services initially developed a target- led implementation model for implementing MCoC. They made implementing MCoC a key priority and then tried to resource it. The goal was set for all women to be able to access a continuity team by March 2023.
The final truth.
Many midwives, a growing number of obstetricians and pregnant women are unhappy or dissatisfied with the implementation of MCoC. Many midwives have been very vocal about the expectation and implications of working in this way and some have left the profession because of it. Some midwives were initially cautious about this change to the way they work and the evidence underpinning it and sat very firmly on the fence. Many have now come down very clearly on the unhappy side of this fence as implementation continued during the pandemic in very stretched and stressed services.
There are now more questions than answers about the implementation of Midwifery Continuity of Carer:
- Is there more evidence available, at service level, to compare full continuity pathways and their outcomes with antenatal and postnatal continuity pathways for 100% of women?
- What is the impact for full continuity pathways for very vulnerable women and women from minority ethnic groups?
- What are the range of implementation models and what are the evaluations?
- What are the unintended consequences of the MCoC?
- What resource is really needed to move forward?
- How can obstetricians and other members of the maternity team provide improved continuity too?
All of these questions - and more - need answers if the NHS is to implement continuity in a safe and effective way.
Finally, the fundamental truth
Any change, however large or small, needs the full engagement and support of the people affected directly by it. They need to feel empowered that the change is possible, that they can deliver it and that they can tick the box ‘this is better for me’.
So, what can we do?
All these truths exist. The pause in implementation in England, requested by the RCM and initiated by the Maternity Transformation Programme, is welcome and is the best opportunity to take time answering these questions. A review of the services that have implemented change, whether positive or otherwise, should be undertaken and the policymakers need to take time to listen and understand the views of all, without criticism. While there will always be a need for leadership from the top, for implementation to be successful, it has to be led by local services themselves, taking account of their local populations and ways of working. This will enable services to improve continuity, in a way and at a pace that is right for them.
If we take this sensible, thoughtful approach, a single truth, shared by all, will emerge, so that women can benefit from equitable, safe and personalised care.