Starting with terminology

When we refer to ‘midwifery continuity of care’ we mean care that usually begins in early pregnancy (sometimes following pre-conceptual care) and continues through pregnancy, labour and birth, to the end of the postnatal period (defined by the World Health Organization as six weeks following birth) (WHO 1999).

Throughout this book, midwifery continuity of care is taken to mean that care is provided by the same midwife or by a small group of midwives who the woman is able to get to know throughout this pregnancy. However we know of situations where the term has been used to describe a philosophy of care employed by large groups of people. For example, there are reports of some ‘team midwifery’ projects where as many as 20 midwives—or more—are organised into a ‘team’, sometimes grouped under a consultant obstetrician who heads the team. ‘Midwifery continuity of care’ is also used in some places to describe situations where midwives only provide continuity of care during pregnancy, such as in a ‘Midwives’ Clinic’. Some people refer to situations where women see different midwives in pregnancy from those who provide care in labour and birth and/or the postnatal period as ‘fragmented care’ or ‘standard care’. Midwives who work in hospitals are sometimes referred to as ‘core midwives’. Many midwives describe the important role that core midwives play in supporting midwives who bring women into hospital, particularly if there are complications.

To aid clarity and provide distance from loose definitions of continuity of care, the phrase ‘continuity of carer’ is sometimes used when referring to situations where a primary midwife provides the majority of the woman’s care through pregnancy, labour and birth and the postnatal period. This type of care is also referred to as ‘one-to-one midwifery’, ‘caseload midwifery’ or ‘midwifery caseload practice’. Continuity of carer is also used sometimes to describe ‘independent midwifery’ where midwives work in self-employed practice outside of the public health service. The concepts of a ‘known’ midwife and a midwife who you have ‘met before’ are drawn from the woman’s perspective and are often difficult to define clearly. Some women will say that they had a midwife they knew even though they only met her once. We have tried not to use these terms as they are often confusing and mean different things to different people. Sometimes ‘community midwifery’ is organised so that midwives have individual caseloads. Community midwifery was the term chosen by the Australian consumer group, Maternity Coalition (2002), in their vision for maternity services that would provide one-to-one midwifery care based in the community. However it is worth noting that the majority of community midwives in the United Kingdom do not provide a caseload practice service, and ‘community midwifery’ can sometimes refer to a system involving antenatal clinics in the community and postnatal home visits, with minimal or no continuity of carer during labour.

A group of midwives working alongside each other with individual caseloads, providing back-up and support for each other, is often referred to as working in a ‘midwifery group practice’. Midwives in a midwifery group practice tend to construct on-call arrangements and annual leave to maximise the opportunity for them to be present at the labours of the women for whom they are the primary midwife, while ensuring they also ‘have a life’! ‘Midwifery group practice’ is different from ‘team midwifery’ where a team of midwives take responsibility for an agreed number of women each month. Midwives in team midwifery models tend to work shifts where they are on-call for the labours and births of all the women booked by the team. We will discuss how team midwifery and caseload practice are organised later in this chapter.

Some controversies regarding terminology

Generally when people use the phrase ‘one-to-one’, they are highlighting the essential characteristics of a model that is also called ‘midwifery caseload practice’ or ‘caseload midwifery’. Some would argue that this model is midwifery since it describes continuity of carer from a primary midwife—as opposed to continuity of care from an indeterminate number of people with a common philosophy. Where there is direct government funding for midwifery, as in New Zealand, some provinces in Canada, the Netherlands and some other European countries, continuity of carer is synonymous with ‘midwifery’, and there is therefore less need to use defining terms or talk about different ‘models’. Indeed, in some countries, the word ‘models’ is seen as counterproductive to pursuing a pure version of what midwifery is—or should be. It has also been suggested that the terms ‘models’ and ‘models of care’ are borrowed from fragmented role descriptions within nursing, and these terms are inappropriate when applied to midwifery. Some people question the use of the terms ‘caseload’ and ‘group practice’ since ‘case’ and ‘load’ may have negative connotations.

Similarly, it has been argued that the term ‘group practice’ may be seen to mask the concept of individual care from a primary midwife. It may be worth understanding the origin of these terms since there were strategic, political reasons why they were chosen in the early 1990s by midwives in the South East London Midwifery Group Practice (SELMGP)¹ (Leap 1996b). This group of independent midwives had previously specialised in providing homebirth services in pairs when they came together to try and ‘contract in’ to the National Health Service (NHS) in the United Kingdom. They secured premises in the Albany Community Centre in Deptford, south-east London, and were committed to working with women who were unable to access or afford independent midwifery services. The midwives were looking for inclusive and familiar words to describe how their model would ‘fit’ within the NHS. The word ‘independent’ was seen as counterproductive when trying to convince NHS policy makers of the value of funding an integrated, community midwifery model involving self-employed midwives. Everyone was used to the idea of general practitioners working autonomously and collaboratively as self-employed practitioners within the NHS in community-based ‘general practitioner group practices’, so it seemed logical to talk about ‘midwifery group practices’. The term ‘caseload’ was also familiar to health service planners, since health visitors and social workers used it to describe the way they had an agreed number of clients for whom they took individual responsibility. Thus the concept of midwives with individual responsibility for providing continuity of carer to a specified number of women per year, working within a supportive group of midwives, became defined in terms of ‘caseload practice’ and ‘midwifery group practice’. Subsequently ‘caseload midwifery’ was adopted as shorthand in many Western countries to describe this way of providing individualised midwifery care from a primary caregiver. The phrase ‘caseload practice’ was to play an important role in identifying the difference between continuity of ‘carer’ and the continuity of care provided by a team of people in ‘team midwifery’. We will return to this discussion later.

Variations in midwifery continuity of care

Midwifery continuity of care occurs in a myriad of different ways across different countries as can be seen from examples throughout this book. There are also differences within countries, with models and services varying from one region, state, health trust or province to the next. This is largely due to the factors listed in Box 2.

Midwifery continuity of care: key principles

Despite variations in the way midwifery continuity of care is organised, there are a number of key principles to ensuring it is effective, appropriate and sustainable. These have been identified by Sandall (1997) and are highlighted in Box 3.

Sandall demonstrated that, where these key principles were in place, midwives did not experience burnout. The converse was also true. We have found these three simple principles are crucial considerations when developing sustainable midwifery models. We return to them regularly when reviewing projects or where issues have arisen.

Job satisfaction for midwives in any situation tends to be based on the ability to develop ‘meaningful relationships’ of mutual trust and partnership (Guilliland & Pairman 1995). This was referred to by Stevens as ‘reciprocity’ in the study of the One-to-One midwifery group practices operating through Queen Charlotte’s Hospital in London (McCourt et al. 2006, Stevens & McCourt 2002). Continuity that builds relationships also enables midwives to facilitate effective access to services, advocate for women when they are unable to advocate for themselves, and prevent some women ‘falling through gaps’ in the service. In addition, a situation is fostered where midwives can listen and act on women’s wishes offering humane, personal care. This is linked to midwives assuming greater responsibility and accountability for their actions (McCourt et al. 2006).

The next section of this chapter will explore how these principles can be addressed when introducing midwifery continuity of care.