MCoCer models that have sustained within the NHS have had supportive leadership from midwifery managers who have the necessary skills, attitudes, aptitudes and behaviours identified within the findings. Sustainable implementation of MCoCer is achieved through development of a values-based recruitment and retention policy within all areas of midwifery and encouraging midwives with previous experience in MCoCer or supportive philosophies towards it, to manage the model.

Providing the appropriate support for MCoCer is time consuming and personally demanding for midwifery managers, however, implementing and sustaining MCoCer was shown by participants who valued MCoCer models to be rewarding, bringing meaning to their midwifery leadership.

• The Albany Midwifery Practice was established within King's College Hospital NHS Trust in South East London and provided care to 2568 women from 1997 until 2009.
• The caseload included high proportions (57%) of women from Black, Asian and Minority Ethnic communities from an area of high social disadvantage.
• Midwifery continuity of carer was high with almost all women (95.5%) being attended in labour by their primary or secondary midwife.
• Spontaneous birth rates were high (79.8%) with a low caesarean section rate (16%). Overall, 43.5% of women gave birth at home.
• Neonatal outcomes were positive with 95% of babies having Apgar scores of >8 at 5 minutes. There were 15 perinatal deaths and no intrapartum intrauterine deaths.

• A systematic review of midwife-led continuity of care models identified benefits for women and babies, with no adverse effects.
• Non-randomised studies have shown benefits of midwifery continuity of care for specific groups, such as Aboriginal and Torres Strait Islander women.
• There are also benefits for midwives, including high levels of job satisfaction and less occupational burnout.
• Implementing midwifery continuity of care in public and private settings in Australia has been challenging, despite the evidence in its favour and government policy documents that support it.
• A reorganisation of the way maternity services are provided in Australia is required to ensure that women across the country can access this model of care.
• Critical to such reform is collaboration with obstetricians, general practitioners, paediatricians and other medical professionals involved in the care of pregnant women, as well as professional respect for the central role of midwives in the provision of maternity care.
• More research is needed into ways to ensure that all childbearing women can access midwifery continuity of care.

• Contact Trixie McAree at Trixie.mcaree2@nhs.net
• Access the maternity workforce tools, designed to help midwifery leadership plan and design maternity services that meet the vision of Better Births and the NHS Long Term Plan.
• Visit our Midwifery Continuity of Carer area of the hub to find more guidance, research and personal reflections from frontline staff.

Note: Subtitles are available by turning on the caption mode in YouTube.

Would you like to share your insight on the continuity of care model? 

Perhaps you know women and families who would like to share their experience? 

You can get in touch with Patient Safety Learning by emailing us at content@pslhub.org

Further reading:

Measuring Continuity of Carer: A monitoring and evaluation framework (November 2018)

NHS: Targeted and enhanced midwifery-led continuity of carer

RCM: Can continuity work for us? A resource for midwives

Can you tell us a bit about yourself and your role?

I am a Consultant Midwife, there are around 100 of us in the UK. I have a relatively unique role in that I spend 50% of my time in the Trust and 50% of my time at the University. I’m currently leading the development and implementation of continuity in Worcestershire. 

When did you first work in a Continuity of Carer (CoC) model?

I became a caseload midwife (CoC) within weeks of qualifying as I knew this was the way that I wanted to practice, and the first team was being set up locally within a designated Sure Start area. Although I have had a number of different roles in the NHS, this was definitely one of the most formative.

Can you tell us more about your experience?

It was an amazing job. I had a fantastic and supportive team and the families cared about us too. Because of the relationship we had with our women, we could see when things were not well or had deviated from what would be expected. 

Women never called us in the middle of the night unless they needed us, so when those calls came in, we knew how to react based on the woman herself and navigate the system on her behalf. This was especially important where some of our families could not advocate for themselves as they were new to the country, had limited English or were socially vulnerable. We became a part of that community. 

How would you describe the CoC model you are rolling out in Worcestershire?

We have a mixed risk model, based on postcodes. Midwives work in a small team of no more than eight, organising their own workload and availability. The teams cover 24/7 availability sharing the responsibility of this.

How do you think CoC can impact on patient safety?

Continuity of carer absolutely impacts patient safety, both physical safety and psychological safety. 

Pregnancy and childbirth are intense, life changing events and each woman and her family will have different needs as well as perception of risk/safety. The relationship that is built over time gives a platform for women and midwives to work through these together, advocating and working with the multi-disciplinary team (MDT) to ensure the safest care is achieved with the woman in control of her care.

CoC midwives also have flexibility in the way that they work to meet the needs of those in their care. If more time is needed with a family, then that is what happens. 

Do you have any statistics or data to highlight the impact of CoC?

Our first year statistics showed an overall decrease in medical intervention and an increased choice to have babies at home and in midwifery led units. Care is wrapped around the women and they drive the choices about their care and their birth. The midwives support them and navigate the system with them. The diagram below shows data for the first two teams at the end of their first year (there is a downloadable version attached at the bottom of this page too). 

What are the barriers to implementing CoC?

There remains significant mythology about what continuity of carer is and isn’t. 

For this reason, many midwives may be reluctant to work in these models as they perceive that they will be working more than they are now. The relationship established with women actually reduces workload, as when they call you, or are in labour, you know who they are and their history. 

Also, the NHS has had a fairly prescriptive approach to system set up and this all changes when you work in continuity of carer teams. The team is given the autonomy to self-manage their daily work, their annual leave and how they cover availability.

What support do maternity teams and individual staff members need to successfully implement CoC?

This needs to be a whole system approach. Individual midwifery CoC teams can support each other, but the wider maternity team need to understand the role of the CoC midwife and how all members of the multi-disciplinary team are involved with care. 

Teams also need to learn to work together and negotiate their time with each other. There is a learning curve to this. The whole system is learning as well as teams and the individuals within it. 

Also, there is a 'bedding in' period that can take some time. This is so new and because each team will develop their 'own way' there is no one size fits all (much like the care that they provide!). 

Do you have any advice for maternity teams considering setting up the CoC model?

Do it! It is an incredible way to work. Empowered teams will empower families.

Embrace the journey, work together, establish team rules and philosophy at the start and review regularly and most of all, communicate. 

Any final thoughts?

I’m really passionate that we roll out CoC for most women and that we do it in a sustainable and effective way. 

I think that it is a bold and brave move forward, and is of significant benefit to service users, midwives and the system. I have worked in this way and found that the relationship and trust built with the families and the team was unmeasurable. 

On a more personal note, I gave birth to all of my children in this model and know first-hand how much this can impact confidence and trust not only in yourself, but those caring for you.

The benefits of Continuity of Carer (CoC) within antenatal and postnatal care, and the implications for patient safety are well reported.

As a midwife, to know the person from booking to postnatal means I am aware when their mental health may be deteriorating, or when they may be experiencing relationship difficulties. It also makes me feel more confident to challenge situations, including potential safeguarding concerns or welfare issues. If a person trusts in their relationship with their midwife, they are more likely to confide that they are struggling, and we'll be better placed to support their health needs. 

Supporting people within their wider context

Community midwifery is not just caring for a person’s physical needs. It’s knowing their family, their housing situation, their past social history, understanding their vulnerabilities and hearing them when they tell us that something isn’t right – whether that be in relation to their pregnancy, their relationship or their mood. This is incredibly difficult to achieve without CoC and is frustrating for both midwives and pregnant people. Midwives want to offer excellent care and pregnant people deserve excellent care.

I recently visited a family who were struggling financially. Although I was aware of their financial predicaments, I had no idea the extent of the issue. I went one afternoon for an antenatal visit. The atmosphere was very tense, and I had heard raised voices upon approaching the house. When I entered the house, their child was crying and shouting, and the parents were distressed. Because of the strength of the relationship we had developed during the pregnancy, I felt able to challenge the couple about what was happening and what I was experiencing with regard to the tension between them. 

I was informed they had no food and had to get through the weekend with nothing to eat. The mother had been too scared to tell anyone in case her children were taken away from her. This opened up a conversation about their welfare generally and we were able to work together, with other support services, to meet the immediate crisis and attempt to start dealing with the ongoing issues.

Monitoring mental health

Another person disclosed at booking some historical mental health issues. She had been fine for a few years and had not required treatment recently. During an appointment a few months later, I felt I wasn’t experiencing her like I usually did. It wasn’t anything obvious just a ‘sense’ that she was holding something back. I gently probed her, and she informed me she had been struggling with anxiety in relation to hypervigilance regarding the baby’s movements. 

We spent some time working on strategies to manage this anxiety and, aware of the clock ticking during a short antenatal appointment, I arranged to see her for a double appointment at my next clinic and referred her to the mental health midwife for ongoing support.

In times of loss

Something we rarely talk about as midwives is loss. 

Caring for a family from booking, to finding out the baby had died, to birth and beyond, taught me a lot about the power of CoC. Being present when the couple met their baby and supporting them for as long as they needed postnatally was an enormous privilege. Although challenging because of the depth of grief, knowing I could make a small difference to their experience, because I knew them and they trusted me, meant we were able to discuss very difficult decisions over a cup of tea whilst the other children ran around us bringing a level of normality to a very awful situation. 

Relationships matter

I have received some amazing feedback from families regarding CoC. Recently a woman said that the strength of our relationship was important to her because she trusted my judgement and ability to advocate for her. She said her experience of CoC had made something that was terrifying to her “not so scary”.

Thank you cards I have received always comment on the strength of the relationship. Over and above any other element of care a person has received during the pregnancy continuum, the relationship and the patient feeling like I ‘know’ them is what they reflect on when we are saying goodbye (which is the hardest part of this model of care!).

As a midwife I get amazing job satisfaction from taking a family from booking to birth to discharge. The privilege of being present during such a life altering time in a family’s life whether it be a first baby or tenth baby, leaves a mark. 

Every family I look after leaves a footprint.

If you'd like to share your thoughts on the Midwifery Continuity of Carer model, you can join the conversation here. 

This document summarises the policy expectations and then suggests a measurement framework that draws on existing data, or that can be incorporated into other existing data collection thus imposing minimal burden on health care organisations and staff. It provides clarity in terms of how continuity of carer is to be defined and measured, and benchmark data upon which improvement can be measured.