There has been a lot of talk recently about continuity of care in maternity services. The recent National Maternity Review report, “Better Births’ raised that ‘some midwives had commented positively on the option of a ‘case-loading’ model’. It also highlighted that women said they ‘see too many midwives and doctors’ which then meant it was hard for them to ‘build up a rapport with healthcare professionals.’ It also highlighted that preterm births have shown to be reduced with continuity and where a women gives birth should not affect her continuity of care.
There are certain women for whom continuity of care could make a real difference and who would benefit greatly from the relationships and trust continuity would bring. #Matexp is currently running a project called ‘nobody’s patient’, addressing those that may fall though the gaps and don’t receive the specialist care they need. Maybe it is these very individuals that stand to benefit most from continuity?
So who could benefit from continuity of care in maternity services? For some pregnancy and giving birth can be especially challenging. Who do we mean and why would continuity of care benefit them?
For some women pregnancy is an incredibly difficult time. Maternal illness can present in many ways including Hyperemesis gravidarum (HG), diabetes, high blood pressure/pre-eclampsia, as well as other pre- pregnancy illnesses such as heart complaints, neurological diseases and epilepsy. These a just a few. For women affected by maternal illness having someone over their care that knows their history, care plan and choices can be invaluable. It provides a relationship that is supportive because the complications are known and the management of them can be closely monitored and reviewed. Trust is important because choices will need to be discussed and when all parties know the relevant history, as well as the individuals circumstances, it can help alleviate much frustration and time for all involved. Usually women with maternal illness will be under the care of a consultant, but contact with the same person and knowledge that care provided will be by the same staff both before, during birth and after, can do much to help their maternity experience to be positive and respecting of choice. It also means that any advice given or support would be inline with their medical needs and consistent, reducing confusion or the need for constant explanations. One family told me that they had to tell every single person they saw all though pregnancy and after birth regarding the woman’s heart condition because they never saw the same person and how utterly frustrating this became, sometimes even them being given conflicting advice.
Perinatal Mental health
Perinatal mental health in pregnancy is an area that the maternity review highlighted needs more support. In fact around 20% of women will develop a mental health problem during pregnancy or the first year after birth. This doesn’t include the many women who become pregnant who already have a pre-existing mental health condition. Mental health issues can be isolating, frightening and overwhelming. During pregnancy a women can be especially vulnerable to anxiety,depression etc as they adjust to their feelings, hormonal changes and worries about approaching parenthood. Continuity of care can enable the building of a trusted relationship that allows for discussions on feelings and concerns. When relationships are built, it allows for honest reflections on how to manage difficult anxieties and also allows for those caring for a women to get to know them well so they can pinpoint when they may be struggling and need extra support. This can be especially important after birth when mental health issues can surface. Having someone trusted, that a women and her family can approach and seek support from, can make a massive difference to early intervention. It also provides a ‘gatekeeper’ so to speak, someone that can help a family find support, liaise with other healthcare professionals or services. This can especially be useful when questions regarding safeguarding may arise. Continuity of care can mean someone to be there when a women feels at her most vulnerable.
There is a two fold part to continuity of care with regards to stillbirths or neonatal deaths. Firstly for those that sadly lose babies, to have around them those that they have built relationships with can be a source of support and comfort. I have heard many times the stories of families who have been contacted after the loss of their baby by healthcare professionals who were seeking to visit or do checks and were unaware of the family’s loss. Making sure that care is continuous allows those that are being cared for to be given respect and dignity at such a difficult time. It means that they instead of being ‘nobody’s patient’ are very firmly supported and cared for. I have heard families mention that their GP was a lifeline during their time of loss, having spent time with the family and being aware of their situation, needs and wishes they provided a ‘constant’ in a sea of uncertainty.
So to also those families that have suffered a previous loss and are now pregnant again. This can raise much understandable anxiety and worry, as well as much needed discussions on ways to support the current pregnancy and birth in ways that help alleviate some of the concerns. It also means that those caring for the family are fully aware of their previous loss and so can be there for the family at the subsequent birth providing a friendly, calming face, or hand to hold at a very anxious time. Trust again here is a big factor and continuity can help a family trust in the care around them but also in themselves.
Ideally every trust would have also a bereavement midwife and health visitor that could provide specialist support and services for the families as needed.
Here again continuity of care has a two fold benefit. If a woman has a difficult birth experience being surrounded by those who she trusts can do much to reduce the trauma. It also allows for free sharing regarding her feelings around her birth experience that can do much to give support and help at this difficult time. Often women can struggle with their feelings around their birth experience especially when to others it may have seemed like an ‘ok’ experience. Having a relationship built up during pregnancy and the birth, means a women will feel more able to speak up and seek help if she is struggling. This also means knowing the women well, those caring for her may pick up on signs of distress or concern, again early invention can often have a massive impact.
For a woman and her partner that have had a previous traumatic birth, continuity of care can be invaluable. Women can struggle to talk about their experience, so having someone that knows their history mitigates the need to re-tell this at every appointment which can be upsetting. It also means that trust can be built or sometimes rebuilt, as trust can often be shattered by a difficult birth experience, but this is desperately needed for families to feel supported and confident.
Having continuity can go a long way in both reducing trauma but also in helping those with previous difficult experiences to have a positive outcome, which was highlighted in the national maternity review.
Diagnosed illness or abnormality in baby.
For families that during pregnancy are told that their baby will have an illnesses or disability/abnormality it can be devastating. Questions, concerns, worries and choices will be many and often overwhelming. There can be great anxiety regarding how parents will cope, who to seek help from and what may need to happen during/after birth. Here again as already said above, relationships are often the key. Trust for when choices need to be made, having someone they can go to for frank discussions, to ask questions and find information. A face they know, trust and respect that knows them and their situation, prognosis and wishes can bring such invaluable support to families. Sometimes choices may not be available to the family that they had hoped, such as a vaginal birth etc, but being able to discuss this and process the many feelings that a family will encounter is important. Also having someone that they can call on to signpost them to support and specialist care and can advocate for them can easy worry and provide relief.
These are just a few of the families for whom continuity of care could make a difference, there are many more. Continuity may help those that fall though the gaps to no longer be ‘nobody’s patient’. So while the idea of continuity of care is something that would benefit many and something to strive for, it may yet be a way off. For some staff it would raise issues around working hours. Other staff may feel that in the current system is just would not be possible. A change in culture, a different way of working for staff and services and innovative ideas will all need to looked at and adopted. There is much work going on and many great discussions talking place, building on these and listening to all voices is important.
For the families that this could make a difference to, starting in small areas such as with those who have a challenging situations may be the way forward. Looking to areas where they have already implemented continuity of care can show good practice and ideas to base further work on. The challenges however will be big, especially in areas where poverty, health inequality and funds are already depleted. Where hospitals are all already struggling and staff at their limit. Continuity of care maybe be the ‘ideal’, however we don’t live in an ideal word, but, with hard work, new ideas, innovation and by working together sometimes even the seemingly impossible can happen.