2 Midwifery continuity of care: what is the evidence? 
Introduction
Some of the issues around evidence for midwifery continuity of care are also discussed in Chapter 9. This chapter and Chapter 9 complement each other in providing views on evidence from slightly different perspectives. The evidence presented in this chapter supports Chapter 1, where the different ways of actually providing midwifery continuity of care are discussed.
Historical perspectives on midwifery continuity of care
Since the 1980s in many Western countries there has been a movement to build services or practices that enable midwives and women to get to know each other and develop a relationship of trust and confidence (Sandall 1995). This move to regain ‘continuity of care’ has been an important part of the renaissance of midwifery in recent decades. Continuity of care was seen as a fundamental aspect of midwifery practice that had been lost in the move to fragmented, hospital-based care.
Whereas the development of midwifery continuity of care schemes has been seen as a departure from the norm, it should be remembered that the roots of midwifery actually lie in the relationship of ‘being with’ the woman. Until relatively recently, midwives were a part of a woman’s community; they were often kith or kin and were likely to have had some prior relationship with her and her family, and thus continuity was a part of the practice of midwifery (Page 2003).
Although the development of continuity of care reverts to an early principle of midwifery, it has required major shifts in organisation in modern, highly complex institutions and health services, with practitioners often having no previous experience of this way of organising midwifery services. It is significant that the earliest developments of continuity of care schemes were undertaken by midwives who had already practised in continuity of care, many of them as independent or community midwives. Perhaps because there was an experiential understanding of what this meant, the importance of the purpose of continuity was not always made explicit (Flint et al. 1989, Weatherston 1985).
Perspectives on the relationship between women and midwives
The purpose of midwifery continuity of care is to allow women and their midwives to get to know each other over time. This involves not only a personal knowledge of each other, but also the ability to be able to work out, investigate, talk about and consider the complex decisions that need to be made together, bearing in mind understandings about the woman’s needs and expectations, her social situation, and her current and previous experiences of health and health care. Continuity of care is about developing a partnership to provide mutual support, and a psychological contract that is necessary for the best care of the woman during all the phases of childbirth. Aspects of this relationship have been described in a number of publications (Leap & Edwards 2006, Leap & Pairman 2006, Pairman & McAra-Couper 2006).
The relationship between a woman and her midwife is not purely instrumental, and women have described it as being important in itself (Wilkins 1993). There is, however, no point in having a good relationship if the midwife is not skilled and knowledgeable. The relationship has a professional purpose, which is the provision of safe effective midwifery care. This has been described as a ‘professional friendship’ (Pairman & McAra-Couper 2006). Continuity is necessary but not sufficient alone. In addition, midwives practising in this way are helped by an organisational model that should support them in their practice, not only by positive attitudes in colleagues but also through systems of care, consultation and referral.
Midwifery continuity of care should be the right of all women. Inherent in this statement is the notion that collaboration is important. Often midwifery continuity of care has been developed only for healthy pregnant women (so called ‘low risk’ women). This is reflected in much of the evidence presented in this chapter. We believe that midwifery continuity of care should be the right of all women since it is highly likely that all women will benefit from midwifery continuity of care, especially those who have complex pregnancies due to physical, social or emotional factors. It is important to bear this in mind when looking at evidence in order to set up a practice or service. We suggest we should work towards a time when all women can have access to midwifery continuity of care, regardless of ‘risk status’.
Policy supporting midwifery continuity of care for all women
The move towards all women being able to access midwifery continuity of care was spelt out in a recent United Kingdom maternity service policy document ‘Maternity matters: choice, access and continuity of care in a safe environment’ (Department of Health 2007). The report states that maternity services should ensure that women are able to refer themselves straight to a midwife when they first know they are pregnant. The section on ‘Continuity of midwifery care’ (2.12) states:
Elements of continuity of care will include:
If midwives’ roles encompass these elements, it is likely they will have a higher level of job satisfaction too (Department of Health 2007, pp 15–16).
Defining and measuring continuity
In maternity, as in other areas of health care, much of the debate about the definition of and purpose of midwifery continuity of care has been clouded by lack of clarity in conceptual definitions of continuity. This has led to some misleading conclusions being drawn in early work regarding how effective such models are (Green et al. 1998, Waldenström & Turnbull 1998). Our understanding, from more recently published research on the relationship between process and outcome, has shown that models of care delivering informational and longitudinal models of continuity will achieve different outcomes to those delivering relational continuity.
More recent reviews of continuity of health care have tended to conceptualise continuity in a range of ways (Haggerty et al. 2003). All have aimed to develop a common understanding of the concept of continuity in order to understand the impact in different settings. When we refer to midwifery continuity of care in this chapter, we mean continuity over time that allows the development of a relationship in which women and midwives may get to know and understand each other and form a contract of commitment. To this end, this section considers the definition of continuity in detail and uses a conceptualisation drawn from the general literature on continuity of care (McCourt et al. 2006).
Continuity can be defined as a hierarchical concept ranging from the basic availability of information about the woman’s past history to a complex interpersonal relationship between provider and woman, characterised by trust and a sense of responsibility (Saultz 2003). At the base of this hierarchy is the notion of ‘informational continuity’. This concept might be the most important aspect of continuity in preventing medical errors and ensuring safety (Cook et al. 2000), but by itself informational continuity might not improve access to, or experience of, care. ‘Longitudinal continuity’ creates a familiar setting in which care can occur and should make it easier for women to access care when needed, but it does not assure the relationship of personal trust between an individual care provider and a recipient of care, referred to in this hierarchy as ‘relational continuity’.
Box 1 Hierarchical definition of midwifery continuity of care
Adapted from Saultz 2003.
| Level of continuity | Description | |
|---|---|---|
| 1 | Informational | An organised collection of medical and social information about each woman is readily available to any health care professional caring for her. A systematic process also allows accessing and communicating about this information between those involved in the care. |
| 2 | Longitudinal | In addition to informational continuity, each woman has a ‘place’ where she receives most care, which allows the care to occur in an accessible and familiar environment from an organised team of providers. This team assumes responsibility for coordinating the quality of care, including preventive services. |
| 3 | Relational | In addition to longitudinal continuity, an ongoing relationship exists between each woman and a midwife. The woman knows the midwife by name and has come to trust the midwife on a personal basis. The woman uses this personal midwife for basic midwifery care and depends on the midwife to assume personal responsibility for her overall care. When the personal midwife is not available, coverage arrangement assures that longitudinal continuity occurs. |
By arranging these concepts as a hierarchy, it is implied that at least some informational continuity is required for longitudinal continuity to be present, and that longitudinal continuity is required for relational continuity to exist in a midwife–woman relationship. There have been a number of ways of measuring continuity, that is who usually provides care, and for how long: these measurements are normally based on what is documented in the health record (Saultz 2003). However, these do not take into account the content of the visit and the nature of the interaction. Multiple definitions and measures have also made it difficult to generalise about the effect of continuity (Donaldson 2001).
Questions raised by health care reviews of ‘continuity of care’
Given the complexity of the redevelopment of standard fragmented maternity services, such questions are appropriate. The evaluation of such changes requires a very specialised form of research, that is the evaluation of complex interventions (Campbell et al. 2007). It requires an understanding of the processes of organisational change as well as a literacy with different forms of evaluation: this is time consuming and expensive (Freeman et al. 2001).
With such questions in mind, it is easy to see that more research needs to be done on:
Impact of midwifery continuity of care on outcomes
Effect of continuity of care on pregnancy and childbirth outcomes
Sadly, despite so much development work around the world to provide midwifery continuity of care, there are few evaluations with many being marred by inadequate descriptions of the ‘intervention’ and different approaches to the change process and organisation of care. Recent international work has attempted to address this situation and ensure consistency in evaluations of midwifery continuity of care by developing a core set of outcome measures (Devane et al. 2007).
Continuity of care as an access and health gain issue
While a number of midwifery continuity of care schemes have been intentionally provided to more vulnerable and socially at risk groups of women, only recently has attention turned to the relationship between continuity of care, increased safety and access (Cook et al. 2000). This is an attempt to address the poor health outcomes associated with these communities.
Maternal and neonatal outcomes are poorer for women from disadvantaged, vulnerable or socially excluded groups, including women with disabilities, although national level data is often very incomplete. The Report of the Confidential Enquiry into Maternal Death in the United Kingdom for 2000–2002 found that very vulnerable and socially excluded women, including asylum seekers and those who cannot speak English, were at greater risk of suffering a maternal death (Lewis 2004). The previous CEMACH Report (1997–1999) found travellers or itinerant women had the highest maternal death rate among all ethnic groups (Lewis & Drife 2001). Women from some ethnic minority groups are also less likely to be offered and receive prenatal testing for certain conditions.
A range of factors may contribute to poorer outcomes in these groups. These include language barriers and poor communication, unfamiliarity with the health service, concerns about confidentiality, and a lack of provision by services to meet the individual needs of these women. Murray and Bacchus (2005) describe the ‘multitude of barriers to accessing timely and optimal care, including the lack of timely and optimal care, lack of accessible information in appropriate formats, negative and stereotypical attitudes of staff, lack of continuity of care, and poor communication and coordination between maternity and other services’ (p 1340).
In the United Kingdom, the CEMACH (Lewis 2004) has advocated continuity of care as a way of combating the problems of lack of access and follow-up care, inadequate translation, inadequate referrals and poor interagency working. It has suggested:
Women with complex pregnancies and who receive care from a number of specialist agencies should receive the support and advocacy of a known midwife throughout her pregnancy. Her midwife will help with promoting the normal aspects of pregnancy and birth as well as supporting and advocating for the women through the variety of services she is being offered. (p 4)
By 2004 there were 524 Sure Start Local Programs (SSLPs). Research conducted by the National Evaluation of Sure Start (NESS) team investigated variations in the way programs were implemented (their proficiency) and their impact on the children and parents (their effectiveness) (Anning et al. 2007). The report highlighted the achievements of the SSLPs in their holistic approach to implementing the Sure Start vision, and for their efforts around developing sustainable, multi-agency systems for empowering parents, children and practitioners. However the barriers in reaching ‘hard to reach’ groups were difficult to overcome. Those who used services often used several and reported satisfaction with them, but services offered at traditional times and in conventional formats did not reach many fathers, black and minority ethnic families and working parents.
Impact of continuity on women’s experiences of care
A structure that allows midwifery continuity of care also allows the development of a special relationship, one that has some qualities of a friendship (Wilkins 1993). Women who value this relationship and the availability of a known, trusted midwife emphasise the confidence, support and reassurance that knowing one’s midwife provides (McCourt et al. 1998
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