Better births: what midwives think

By Beck Taylor, Fiona Cross-Sudworth, Christine MacArthur on 25 May 2018 Midwives Magazine Better Births Initiative Midwives Research

A survey was undertaken to ascertain midwives’ views on continuity of carer – the authors reveal the findings.

The 44 local maternity systems (LMSs) ACROSS England have been tasked with implementation of the Better births recommendations, including continuity of carer throughout pregnancy, birth and the postnatal period, by 2020-21 (NHS England, 2017; Cumberlege, 2016).

NHS England (2017) has provided detailed guidance to support this work, highlighting the importance of engaging midwives in the development of continuity models. Local teams must decide on caseload size dependent on local population needs, although Birthrate Plus recommends caseloads of up to 36 per whole-time equivalent midwife providing home births and working in freestanding midwifery units (compared with caseloads of 96 for community midwives).

Researchers at the University of Birmingham conducted an online survey of 798 midwives in seven early adopter sites to explore midwives’ perspectives of different ways of working, and to inform the implementation process.

What did the survey find?

Many midwives expressed concern about how their role might change, and about the impact of flexible working on work/life balance and, in particular, the ability to juggle childcare responsibilities. Midwives were also worried about their competence working as a ‘jack of all trades’ across different maternity settings.

Just over a third (35%) were willing to work in a continuity-based model that included intrapartum care across all settings. Almost half (47%) said they would be willing to work across settings, although 59% said they would need to update clinical skills to do so.

There was some resistance to a change of working patterns, with 41% stating that they were unable to work a different pattern to their current role, and 37% that they would be unable to work any on-calls or nights. For those willing to undertake on-call, two to four nights a month was the most preferred frequency. Half of midwives said they felt confident to attend a home birth as the primary carer.

Changing concerns

Most respondents reported barriers to changing the way they work to make continuity happen, suggesting a gap between the number of midwives required to deliver continuity, and the number willing or able to do so.

The survey provides evidence to support many of the issues identified in the recent continuity-of-carer implementation guidance (NHS England, 2017). It is essential that NHS England and the LMS listen to and address midwives’ concerns, and evaluate the safety of midwives working across settings at scale, and the impact of the changes on staff. For the changes to succeed, midwives will need to be behind the plans. They will require support as well as continuing professional education and training to sustain new ways of working while maintaining their own wellbeing. 

Beck Taylor is a postdoctoral clinical research fellow and an honorary consultant in public health; Fiona Cross-Sudworth is a research associate and registered midwife; and Christine MacArthur is professor of maternal and child epidemiology. They are all based at the Institute of Applied Health and Research at the University of Birmingham

To access the full results of the survey, go to


Cumberlege J. (2016) Better Births. Improving outcomes of maternity services in England. A Five Year Forward View for maternity care. See:

NHS England. (2017) Implementing Better births: continuity of carer. NHS England: London.