4 Introducing continuity of care in mainstream maternity services: building blocks for success 
Introduction
Previous chapters have provided an overview of the ways that midwifery continuity of care can be provided, the evidence to inform development, and a mapping process that could be used in the planning phases. Chapter 3 took you through a step-by-step process to understand your context or environment before you start the process of change. The next step is the actual process of getting started. That is the focus of this chapter, which draws on examples and experiences from different settings.
Understanding your community
In planning any new midwifery continuity of care model it is important to involve women who use maternity services. This means engaging women in your planning process who have used, currently use or potentially will use services. We suggest you avoid a situation where you have one token consumer on a steering group or working party if you are serious about consumer representation and participation; at least four is a more suitable number and in some situations it may be appropriate to have at least half of your steering group made up of local maternity service users. You can approach local voluntary or non-government organisations for representatives, but advertising in the local paper or putting up notices in a community centre or health centre can be useful. You may also want to think about approaching women who have recently given birth with your service and inviting them directly, particularly if you want to involve women from specific culturally and linguistically diverse (CALD) communities.
Finding out what women want from maternity services can be fraught with difficulty if women have not had the opportunity to know what might be possible and have never experienced midwifery continuity of care or the service you are considering setting up. It is sometimes hard to imagine a type of care if you have never had it or even heard about it. Sometimes you need to develop an information leaflet describing options and addressing potential concerns. This was particularly important when we were implementing a project that included homebirth as an option in an area where it had only previously been available privately through independent midwifery services. The information leaflet in Box 1 was designed by a multidisciplinary steering group that included four consumers. This group met regularly for two years in order to set up the first publicly-funded homebirth service in one Australian state. Many people, including consumers, midwives, obstetricians, the ambulance service, the risk management group and the occupational health and safety service, were consulted about the leaflet. The leaflet draws on the MIDIRS ‘Informed Choice’ leaflets (MIDIRS 2007), a useful resource whenever you have the task of designing an information leaflet. As you can see, it also provides websites so that people can search for more information if they wish to.
Box 1 Sample information leaflet developed for women accessing publicly-funded homebirth services
CHOOSING TO GIVE BIRTH AT HOME
How to find out more
If you want to talk more about homebirth, please feel free to discuss this with your midwife or doctor. If you want to read more about the research regarding homebirth, you can access the Cochrane Library online on http://cochrane.org/index.htm (please note: in Australia there is free access to the Cochrane Library but this may not be available in all countries) and then type in ‘home versus hospital birth’ in the search space. This review will give you the latest evidence about homebirth.
In addressing local need, you do not necessarily need to do a specific study in order to gather women’s views. Conducting surveys, even small ones, is a big undertaking and if you decide that this is necessary, make sure you find some assistance or support in the design, conduct and analysis. At a minimum though, you should consider the demographics of your area or region and have an idea of what women generally want from maternity services and what is already on offer.
Examining research that indicates what most women want from maternity services will help your planning and development process. There are a number of excellent reports in relation to women’s views about maternity care. In Australia, the research from the Centre for the Study of Mothers’ and Children’s Health in Melbourne has provided valuable insights into women’s views about their maternity care over the last decade (Brown et al. 1999, Brown & Lumley 1994, Laslett et al. 1997). Examples in the United Kingdom include ‘Are women getting the birth environment they need?: a report of a national survey of women’s experiences’ published by the National Childbirth Trust (Newburn & Singh 2005) and ‘Recorded delivery: a national survey of women’s experiences of their care 2006’ (Garcia et al. 2007). In New Zealand, the views of 2909 women who gave birth in February and March 2002 were reported in ‘Maternity services consumers survey’ (NZ Ministry of Health 2002). Finally, in Canada, more than 6000 women responded to a national survey about knowledge, experiences and practices in relation to maternity service provision (Canadian Perinatal Surveillance System 2007).
All of these surveys and reports highlight women’s appreciation of midwifery continuity of care and are useful documents to explore, particularly when making the case for developing a new project. Along with citation of local health department policy documents, the results of surveys often form an important part of your argument in a proposal. The starting point always has to be related to improving services for local women with an emphasis on the advantages of midwifery as a public health strategy (Foureur 2005).
Working in partnership with women to bring about changes to maternity services can be very powerful. For example, in New Zealand, midwives joined with women to bring about significant changes to midwifery and the provision of maternity care. In 1988, the New Zealand College of Midwives was formed with a conscious decision to involve consumers as partners within the organisation (Donley 1985, 1989, 1998). Women and midwives worked together to bring about legislative changes which ultimately meant that women would be able to choose a publicly funded, lead maternity carer (LMC) for their total care throughout pregnancy, labour and birth, and the postnatal period. The LMC may be a midwife, general practitioner or obstetrician. The changes in funding arrangements meant that midwives would be able to practise autonomously, and gain independence from the medical profession (Guilliland & Pairman 1995). The New Zealand experience of women and midwives working together is a powerful example of the value and importance of consumer partnership (Leap & Pairman 2006, Pairman & McAra-Couper 2006).
More information about the process of understanding your community, including addressing hurdles, barriers, professional boundaries, relationships, structures and transitions can be found in Chapter 3.
Preparing the organisation
The strengths might include the number of midwives who want to change to working in a continuity of care project, your supportive manager and the one obstetrician or general practitioner who believes it is a good idea. A weakness might be the fact that you only have four midwives with enough recent experience to practise across the full scope of midwifery practice. An opportunity could include the recent review conducted in your area that recommended the implementation of midwifery continuity of care. Consumers can also be your opportunities. For example, the support of women in your community could be a useful and important strength and an opportunity. Your challenges might be a group of colleagues or managers whose actions have threatened previous changes, or the ongoing challenge of budgetary problems.
Forming a working group
You may also choose to include in your working group (see Box 2) some of the people who you decided could potentially be challenges in your SWOC analysis. Once people are involved in the process of design and implementation it is more difficult for them to be obstructive. Also, the experience of being exposed to evidence and enthusiasm may help change attitudes and beliefs.
Box 2 Possible membership of your working group
Depending on the type of project you are setting up, membership of the working group may include:
The working group can also be a way to gather support and ideas and to have ongoing consultation and discussion. Minutes should be kept and circulated to everyone in the group and made available to staff in the unit, for example, put into the communication book at ward level. The responsibilities of the working group are usually to decide upon the structure of the new project, plan the implementation and evaluation, and solve problems or challenges once the project is up and running. It is useful to draw up Terms of Reference in the form of dot points at the beginning so that everyone is clear about the responsibilities of the group.
