Midwifery Continuity of Carer at the sharp end: Do we take off, taxi the runway or return to the place we came from…?

Joanne Crawford is Head of Midwifery in an England NHS Trust moving toward full continuity of carer for maternity services. She reflects personally on her experience of leading the developments and the challenges faced to support staff through the changes.

Midwifery Continuity of Carer at the sharp end: Do we take off, taxi the runway or return to the place we came from…?

Being a Head of Midwifery is a role I never truly thought I would achieve, although was one I aspired to become.

As an E & F grade midwife; I loved my role and held the wellbeing, confidence and happiness of the women and their families at the centre of everything I did. I believed if I could make one woman feel special, empower one partner to instil confidence in their pregnant and possibly labouring companion, to ensure they felt safe, well informed and cared for with professionalism and compassion then I was doing what I trained 3 years to achieve.

As a labour ward coordinator and practice development midwife, (G Grade), I learnt to have the confidence to influence the team of midwives, health care assistants and doctors and lead them through a shift to keep women safe, aid quality decision making and empower the team to develop their skills and provide compassionate high-quality care.

As a matron, a percentage of my week was not providing direct clinical care, although I was mainly found on the labour ward in every handover and challenging decisions about care for women and driving midwives to be great; but it was at this point I realised that the position I had held the ability to not just influence one woman and one  family or one midwife but a local population of families and maternity staff. This was an opportunity to influence the care families received and I wanted this to be the best.

I then had the opportunity to move provider trusts and leave the security of the team I had worked with for 16 years; a maternity family who knew my daughters, knew my skills, my weaknesses and my passion. I left my safe space to move to a team as the Head of Midwifery (HOM). I have never been so proud to introduce myself but at the same time so vulnerable and so pressured to lead the service with knowledge, professionalism, confidence.  I have the responsibility of making decisions that would influence two acute hospitals and four  community teams (plus gynaecology and sexual health – extra services; I learnt ‘so much’ being the general manager tendering for 2 sexual health services, however I can proudly say my role is now purely dedicated to midwifery).

As a clinical midwife at the start of this reflection and at every point over the past 26 years I have witnessed the significant pressures to midwifery staffing, with the loudest voices being heard in the last 6 years as the HOM. Nationally, it was no surprise that the overall total of registered baby boom midwives would significantly decrease post 2020 (Midwifery 2020) and in the North of the England we saw this decrease much later then our southern colleagues.  Nevertheless, this reduction was evident with a lack of experienced midwives available to fill vacancies in traditional community teams and more senior roles. The service had always had the ability to cover maternity leave with fixed term staff but fixed term was becoming increasing rare.

In this existing model of midwifery, midwives began to lose their identity, almost processing women through a system albeit with compassion and professionalism. Antenatal women are efficiently mobilised through a GP surgery with 15-minute appointments to meet all the health, wellbeing and mental health requirements women need to discuss. This is followed by an invite to stay on a maternity unit when established in labour or invited in for a caesarean section or induction. The midwives who care for these women request their shifts and are then required to attend the unit as per roster. When they arrive, they are allocated a women to care for andaim to look after her during labour as per service guidelines. They are invited to squeeze a break in hopefully and then they hand over to the next midwife after 12 hours; a midwife who has no relationship with the woman or her family; knows nothing about her other than the SBAR hand over at the most vulnerable, intimate, personal time of her life. The exiting midwife then leaves to continue with her life and is dictated to by the roster, when to return for her next shift.

Whilst this sounds controlled and safe; the reality I have witnessed increasingly over 26 years is not a safe and controlled environment, but one that is staffed by a number of midwives that is determined by a roster model, not the amount of women that are present at the hospital needing our care, compassion and professionalism. The rollercoaster of the labour ward can reflect a controlled proactive environment or one that is reactive with a coordinator constructing a minute-by-minute plan to keep the most acute women safe when demand outweighs capacity.

In 2016 when Better Births was launched it provided the country the challenge to totally transform  the model of midwifery, but unfortunately there wasn’t a ‘how to guide’ and instead leaders were supported financially to be trailblazers. The mistake made by many was one of two things; they either invested in small pilot teams or did not believe and avoided the commitment.

What is now apparent is that midwifery continuity of carer (MCoC) has not only provided the vehicle to improve outcomes for women and their families, but the ability to transform the midwifery model to deliver care to women when and where women need it, by a team of midwives that they are familiar with. MCoC provides the opportunity to innovate how midwives are scheduled to enable care to be provided around women’s needs; not a building or roster. This avoids the peaks in activity that currently outweighs midwifery availability.

MCoC midwives will care for a caseload of women supporting them throughout their whole pregnancy journey delivering trust, advocacy, compassion and consistent care whilst reinstating midwives with autonomy, confidence, and flexibility.

This research based quality improvement, has to happen, to deliver the improvements to women and midwives, so why in 2022 have we not achieved this? As a HOM, I have several thoughts at different levels: nationally we have not had, until 2021, a robust recipe to deliver this change, (Delivering Midwifery Continuity at full scale)  and the realisation I have absolutely seen; is that this has to be a full transformation to deliver the equal quality to all. Only with a service providing 4/5 plus teams will there be an effect on acute care; yet we have spent several years focusing on small pilot teams. Secondly; as Boards and DOMs/ HOMs we had a lack of belief, we have not had trust in the workforce tool and how we can safely provide services (with birthrate plus compliant establishments). If the HOM does not believe in the methodology and the ability to deliver then how can the hearts and minds of the organisation engage in the how and when; in reverse if the Board does not engage and support the HOM and the service how can they drive their beliefs .

Hearts and minds are a significant elements to a change as large as this and whether we can engage people in this change will be the key to success or failure.

We are driving a change that will destabilise every element of midwives lives that work in the current traditional model of midwifery. If we reflect on Maslow’s Hierarchy of Needs (1943), our midwives will not be motivated to engage until they know what life will look like for them personally, even though they may understand the theory and how it will benefit women, their individual lives will ‘top trump’ the drive to improve.

This reflection; is based on the role of the HOM and how leading a change at this scale is reliant on the belief in the model and the true effect it will achieve for women and midwives, maintaining strength in that belief when the majority of midwives do not agree that change is the right thing to do and place the level of perceived personal negative effect this change it will have on them at your door.

The hardest thing is to maintain that belief whilst on the journey to an improved professional life. It is a struggle to maintain belief and support staff on that journey ensuring their seatbelts are on and the building blocks are there for staff to understand the detail of the journey ahead and trust in you.

Being a HOM is like being a pilot that has identified that the place we all are at the present time is not the safest, ‘happiness’ place. We are unable to deliver the best care we can in maternity services or to allow midwives to practice and utilise their inherent skills and support their personal job satisfaction or have a good work life balance.

MCoC has shown us, where we can be to achieve all of these things; however there have been few midwives that want to get on that flight, mainly because they have not seen the new place fully and cannot feel or understand what it will be like on a daily basis. So, because of this fear of the unknown and perceived perception of what it will be like; midwives suddenly feel the place they presently are is good and satisfactory, although for the last 26 years in my career this has not been midwives interpretation.

The HOM has to provide the level of detail (the workforce tool and building blocks) to the midwives to try to encourage them to get on the plane and sometimes, for the greater good, we may need to make the flight part of the role of the midwife in their organisation and then the role is to help them on that journey. It is not only the midwives and other staff in the service including the medical staff that need that detail, but the ability to succeed in this flight and journey to a better place rests on the provider Board. The Board are the flight tower and unless there is permission to take off whatever the strategy, the flight will continue to taxi on the runaway, neither in the new better place or fully in the place not deemed sustainable. So it is essential to get the support and buy in from the Board.

It really the hardest thing for a HOM to do in flying a plane that lots of people don’t want to be on;some do, but are apprehensive and some in fact will choose to not get on at all. But the aim of the flight is to get to that new place, settle in get to know the new world and, based on the midwives that are already there, the main aim for this HOM is to start to see midwives smile again, to hear how they feel like real midwives and

“it’s the first time I have ever been able do what I trained for”;

“ I see my family more and I am no longer a midwife that is exhausted after long understaffed labour ward shifts without a break or finishing safeguarding referrals after a clinic back to back with 15 minute appointments at 7pm”.

That has to be the past and the place we have left behind. And just for information, there will be more flights to this place and we will welcome more midwives who want to practice in the new place to join us and deliver MCoC to all our women and families.

Prepare for takeoff…..

Joanne Crawford

Head of Midwifery

This pilot could not get off the runway without the great flight tower (Board) and the most fantastic team of co-pilots and cabin crew; MCoC project lead, matrons, clinical leads and team leaders. Seatbelts on Team.