Humanising childbirth in the aftermath of the Final Ockenden Report: continuity of relationship and listening to women, partners, and families
Standing back, taking a considered view, and thinking about how we might build on the Final Report of the Ockenden Review to put women, their babies, and families at the centre of our care and concern, is a critical part of a response to the failures of care, and their tragic consequences described in the report.
The immediate and essential actions (IEAs) set out in the report have been accepted by the government for England’s maternity services. Building on these IEAs, Birthrights emphasises the need to create the deep cultural change required ‘to really put women and birthing people at the centre’ of maternity care.
Knowing just how vitally important, just how sensitive, the time around pregnancy, birth and the early weeks of life is, the distressing outcomes that arose from failures in care, at every level, of the Shrewsbury and Telford Hospitals NHS Trust must increase our resolve to prevent such avoidable tragedy from happening again. Making care as physically safe as possible for mothers, birthing people and babies is the absolute minimum that should be expected of any maternity service, anywhere.
However, we should do much better than this to make care psychologically and emotionally safe. The aim must be to humanise care, along the lines of maternity transformation arising from Better Births. This requires deep cultural change, as well as the strengthening of the systems that underpin health services, and changing the way in which care is provided, to include the maintenance and implementation of Midwifery Continuity of Carer (MCoC).
Rather surprisingly, since MCoC is not mentioned in the report as being an issue, and CoC by medical staff is praised, the Ockenden review makes recommendations about review and suspension of MCoC until and unless safe staffing is shown to be present (p14).
As a consequence, some NHS Trusts have started to withdraw midwifery continuity of carer models, even when safely established, and even when it is providing benefits to women and babies. Reversing the implementation of continuity of care, within Trusts and nationally, will be harmful and take away a necessary foundation to care that revolves around the woman and her baby and family.
Yet, other non-safety critical areas of maternity care that occupy midwives time, are not challenged as barriers to safe staffing levels. These include fragmented care, excessive bureaucracy and record keeping, and routine interventions applied to individuals where this may not be what they want or need. Unnecessary and unwanted induction of labour for otherwise healthy women before 41 weeks is a case in point, especially when women have not fully consented to these procedures on the basis of adequate information.
In Parliament, the value of continuity of carer has been recognised. In response to Jill Mortimer MP (Hartlepool, Con), Sajid Javid Secretary of State for Health and Social Care, stated:
‘Yes I agree very much with my hon.Friend and I thank her for sharing with the House her own valuable experiences. She is right to talk about the importance of continuity of care, and that is part of our maternity transformation plan. (Ockenden Report, Hansard volume 711, Wednesday March 30th, column 826)
The importance of CoC in risk identification (a fundamental safety tool) has been recognised at the highest level. On January 17th Jeremy Hunt MP, who has been highly supportive of families involved in maternity reviews since the Morecambe Bay report, said the following in an evening debate in parliament:
On the point made by the hon. Member for Strangford (Jim Shannon) about staffing levels, does she agree that one of the most important reasons why we need to fill the staffing shortfalls—the 2,000 extra midwives needed immediately—is that we need to be better at identifying higher-risk pregnancies? Continuity of care, so that people are looked after by the same midwife throughout the pre-natal, birthing, and post-natal periods, is an incredibly effective way to do that. (Midwives in the NHS, Hansard Volume 707, Monday 17 January 2022 column 170)
The call to pause, suspend or stop the roll out of continuity of care schemes is particularly puzzling in the light of the emphasis in the report on listening to women, and on the need for increased safety.
Continuity of carer (CoC)is the feature of care most commonly demanded by pregnant women.
If we are genuinely to listen to women, we must acknowledge that they have consistently said that they want continuity of carer. From over 20 years of policy including the most recent, Better Births, this has been a clear theme. The most recent Care Quality Commission (CQC) survey of women’s experiences concluded that:
‘Women who had continuity of carer, women who have had a previous pregnancy and women who had an unassisted vaginal birth consistently reported better experiences….’
Continuity of carer is therefore critical both for safety and for personalisation. For most, CoC will be provided with midwives, but, for women with pre-existing medical conditions or complications, continuity of medical care should also be rolled out. The process for implementing midwifery continuity of carer while maintaining safe staffing is already set out by NHS England. To ensure safe and personalised care, it should be provided for the majority of women.
A shift towards humanising care must start with an understanding of the significance of childbirth to individuals, community, and society. Such a shift requires leadership that genuinely aims to provide culturally, socially, and psychologically sensitive health and medical care, that responds to the unique personal and health care needs of every woman, birthing person, baby, and family, rather than the needs and routines of communities, institutions, health services and professionals. To be effective, this must be the aim of every maternity care policy that drives service organisation and practice, and of every provider at all levels of the system.
This is the polar opposite of what happened on the occasions where things went wrong in Shrewsbury and Telford NHS Hospitals Trust, and in the failures experienced by some women, babies and families in other NHS Trusts and Health Boards in parts of the United Kingdom.
An essential part of the deep cultural change needed, will be to build organisations that enable relationships of trust to develop as a fundamental and required part of ‘business as usual’ in everyday service delivery. These relationships need to exist between women, and their carers, and between and across midwives, doctors, and other maternity care providers.
To build relationships over time, to form relationships of trust, between staff and service users, and to allow staff to have time to care properly, as they want to, it is critical that continuity of carer (CoC) is successfully implemented. Based on the highest possible evidence available, that is contained in a Cochrane Review, models of MCoC reduce overall fetal loss before and after 24 weeks’ gestation plus neonatal death. CoC is also the only intervention that has been shown consistently to reduce premature birth.
Midwifery continuity of carer enhances safety and is a model that enhances the ability to listen to women, and to work with individual women, supporting them to make decisions about the kind of care, the kind of birth, that is right for them. Given the evidence cited above, and other advantages of MCoC, a return to, or maintenance of, the highly fragmented system that exists at present will most likely increase risk, reduce positive experience, and affect outcomes.
Leading charities recognise the vital contribution the maintenance and further implementation of MCoC will make.
Birthrights, one of the leading human rights advocacy groups for women is ‘surprised the report did not place more emphasis on the powerful evidence-based contribution that continuity of carer can make’.
AIMS, the Association for Improvements in Maternity Services, resolves to ‘Work with others to press for the continued careful implementation, within the context of safe staffing levels, of a relational model of maternity care, or Continuity of Carer, so that this model of care becomes the default model of care across England as currently planned…’.
Continuity teams can only work, however, when they are established on what we know makes them work. This includes flexibility in care provision, professional autonomy to manage one’s time, and clear pathways and collegiate relationships that allow mutually respectful consultation and timely referral, as well as management that supports rather than controls. Appropriate caseload numbers are needed. CoC schemes must be integrated into standard care, and not seen as an add-on, where CoC staff can be pulled into labour wards or other areas of the service without notice. When set up and managed appropriately MCoC offers midwives who wish to practice in this way increased satisfaction and protection from burn out. Considerable help and support and detailed, well founded, guidelines are available from NHS England. This planning guidance offers advice and tools that will help roll out MCoC without jeopardising other parts of the service.
We cannot go on as we are. Continuing to provide fragmented, impersonal, unsafe, and disrespectful care that is not flexibly tailored to each woman is not an option. Piecemeal change, built on top of existing non-functioning systems, beliefs and assumptions, will not work. Fundamental transformative change in the very philosophy and basic structures of maternity service provision is needed. The effective implementation of genuinely safe and personalised continuity of carer schemes is vital for achieving this imperative. Subsequent maternity review reports have noted problems for women and partners in communicating with the Trusts involved and getting action. Continuity of care enables midwives (and doctors where they are offering this kind of support) to be the advocate for individual women.
Continuity of Carer is not part of the problem, it is a vital part of the solution. Urgent work is needed to rationalise other aspects of the midwifery workload to improve face to face staffing levels, while also recruiting and retaining more staff so that, where it has happened, any suspension of continuity of care implementation can be lifted, and ongoing roll out is supported.
Listening in all contexts is essential, both within and beyond CoC, including keeping choice of place of birth in place, listening when women tell us they think something is wrong and listening to their grief and sadness when things do go wrong. While this listening: and responding- can be done in all models of care provision, it is more likely to become ‘business as usual’ when working relationships are formed through continuity of care. The voices of women over many years, and the mounting evidence of its contribution to safety, mean that continuity of care is vital for truly transformative maternity services change for the future.
Lesley Page Visiting Professor in Midwifery Florence Nightingale Faculty of Nursing, midwifery and palliative care, Kings’ College London and Adjunct Professor University of Technology Sydney
Soo Downe Professor of Midwifery Studies School of Community Health and Midwifery University of Central Lancashire
Alexander Heazell Professor of Obstetrics and Director of the Tommy’s Stillbirth Research Centre, Manchester Academic Health Science Centre
Alison Macfarlane Professor of Perinatal Health City University of London