By Caroline Flint

Caroline Flint describes her pilot for a scheme where three midwives cooperate in providing continuity of care for their patients - who would benefit from knowing the midwives who gave antenatal care and deliver the baby. The scheme would also improve the midwives' job satisfaction

Continuity of care is something we pay lip service to as being `a good thing', something our patients desire very much', something only community midwives can achieve nowadays - but I believe continuity of care is far more important than we have so far realized.

With the use of ever more sophisticated monitoring of both the pregnant and the labouring woman in an attempt to lower the perinatal mortality rate, I think we may have lost sight of the most simple fact of all - that the same hand on the same abdomen every month (and then every week) picks up discrepancies which the usual medley of people who examine a pregnant woman easily miss.

We know the perinatal mortality rate rises with women who default from antenatal clinic attendance. One of the bonuses of continuity of care is that very few women miss an appointment; in my experience, if a woman does miss an appointment, she will turn up the following day or in a couple of days.

Why don't women miss antenatal visits when they are seeing a continuous person? Why do women want continuity of care? When they have it, why do they love it so? My proposition is that in this situation the continuous person (that is, the midwife) can get to know each woman as an individual. When the patient comes into the room, she can be addressed by name, her worries or joys of the previous visit can be remembered. `Hello, Joan, how did your move go?' or: `Hello, Rachel, did your boyfriend get the job?' is a very different approach from: `In here please, mother, and onto the scales.' Women appreciate being treated as individuals and respond with regular attendance.

Relaxed and realistic

Women experiencing continuity of care are more relaxed, they know their medical attendants as friends, they are not embarrassed or reticent in bringing up personal fears or worries, they feel more confident, and their expectations for labour can be discussed and noted - with realistic prospects that these can be carried out at the time.

I believe continuity of care could be the most decisive factor in the future reduction of the perinatal mortality rate, and probably the most influential factor in enhancing the quality of the experience of giving birth for both the expectant parents and their child.

How can we achieve continuity of care in the hospital setting? Can it be done? I believe it can - but that it needs a radical rethink in our use of midwife hours, and that it needs very special midwives to start the scheme. I also think that initially, and perhaps subsequently, not all patients could be included in it.

Involvement

Here is my plan for a pilot scheme achieving continuity of care throughout the antenatal period and during labour and delivery, by a team of three midwives. Between them, they can give antenatal care to and deliver 468 patients a year, and following delivery they can visit their patients in the postnatal wards.

The midwives will be working flexitime, coming in to their patients when they are needed but having definite off-duty days and on-call days so that they can plan their lives in advance.

This pilot scheme is for continuity of care during the antenatal period and delivery, but obviously the ideal would be to carry the concept through into postnatal care too. I would welcome suggestions and comments on how this could be achieved.

Emma becomes the first continuity midwife. She has been employed specifically to inaugurate the scheme and thus she needs to be someone who is settled in her private life (she will need to be involved in the scheme for at least two years to see any results), she needs to be on the telephone and she needs a car for which she is paid at the standard user rate.

Emma will be employed for 40 hours a week or 80 hours a fortnight. She will control her own off-duty and may find it helpful to have a clock-on, clock-off card or a card she fills in with the times she comes on or goes off duty.

Let us imagine that Emma starts working in the antenatal clinic in March. In the first month, she books 36 patients who are 12 weeks pregnant (nine a week) and explains to them about the continuity scheme. The continuity patients are allotted 15 minutes for every antenatal visit and Emma does all their care except that on their visits at 16 weeks, 32 weeks and at term, the patients also see the consultant obstetrician. Emma takes histories, weighs the patients, tests urine, takes blood pressures, tests for oedema and palpates the women's abdomens.

The following month (April), the 36 patients return and Emma also books another 36 patients who are 12 weeks pregnant. In May, Emma antenatals the 36 20-week pregnant patients, the 36 16-week pregnant During the next couple of months, the two midwives will be seeing the following antenatal patients and books 36 12-week pregnant patients and so on.

Patients seen in June
36 at 24 weeks
36 at 20 weeks
36 at 16 weeks
36 at 12 weeks

Patients seen in July
36 at 28 weeks
36 at 24 weeks
36 at 20 weeks
36 at 16 weeks
36 at 12 weeks

Patients seen in August
36 at 32 weeks
36 at 30 weeks
36 at 28 weeks
36 at 24 weeks
36 at 20 weeks
36 at 16 weeks
36 at 12 weeks

By August, Emma will be seeing 252 patients during the month. This will take her about 63 hours. Her other hours on duty are spent according to the demands of the service. As the first deliveries are approaching, she will need to be joined by the next member of the team, Joan.

Joan, like Emma, needs to have a telephone and a car. The scheme must be explained to her very thoroughly so that she knows what she is taking on, and she and Emma need to be compatible because they will be working so closely together.

Patients seen in September
36 at 36 weeks
36 at 34 weeks
36 at 32 weeks
36 at 30 weeks
36 at 28 weeks
36 at 24 weeks
36 at 20 weeks
36 at 16 weeks
36 at 12 weeks

Patients seen in October
36 at 40 weeks
36 at 39 weeks
36 at 38 weeks
36 at 37 weeks
36 at 36 weeks
36 at 34 weeks
36 at 32 weeks
36 at 28 weeks
36 at 24 weeks
36 at 20 weeks
36 at 16 weeks
36 at 12 weeks

By October, the scheme will be fully operational and Elizabeth, the third midwife, will join the team. Like her colleagues, she needs a telephone and a car and needs to be enthusiastic about the scheme.

The three midwives are now seeing 432 antenatal patients a month. They arrange their clinics as follows:

Monday: One midwife

12 patients seen between 13.00h and 16.00h. 12 patients seen between 18.30h and 21.30h.

Wednesday: Three midwives

24 patients seen between 09.00h and 12.00h. 24 patients seen between 13.00h and 16.00h.

Friday: Two midwives

24 patients seen between 09.00h and 12.00h. 12 patients seen between 13.00h and 16.00h.

Total of 108 patients seen during the week.

Each midwife has two days off a week. The off-duty and on-call rota for October is shown in the table.

The scheme swings into action on Monday, September 30. Joan, on call since 18.00h on Sunday evening, arrives at the hospital at 06.00h - after being phoned by emergency control - because Mrs Askew has gone into labour. She will stay with Mrs Askew until she delivers (unless anything very unusual crops up).

Elizabeth comes in at 13.00h and sees 24 patients during the afternoon and evening. At 17.00h, Joan pops down to see Elizabeth on her way home from delivering Mrs Askew, and also Mrs Brown, who came in in strong labour while Joan was in the labour ward. Joan reports that Mrs Askew and Mrs Brown very much appreciated being delivered by a midwife they knew.

Elizabeth finishes her clinic at 21.30h and goes home. She is on call tonight and is called out at 03.00h to Mrs Cook, who is in false labour; Elizabeth is home again in two hours and goes back to bed. However, at 08.00h she is called again to Mrs Devi. She stays with Mrs Devi, delivers her, and leaves for home at 16.00h. Elizabeth has now worked 18.5 hours, but Emma is only now starting her week.

During Wednesday, the three midwives see 48 patients, and have a chance to liaise with each other and to visit their postnatal patients in the wards. Before the clinic finishes, Emma is called away to Mrs Farrow, who is in labour. During the evening, Mrs Cook returns to the labour ward, this time in established labour. Emma does not finish her night's work until 02.00h, and when she leaves for home she will have worked for 16 hours.

Emma and Elizabeth both spend Thursday at home because they have no one in labour, Joan is on a day off.

On Friday, Elizabeth is called out at 04.00h to Mrs Gudka, who is delivered at 10.00h. Elizabeth then goes to join Emma doing the antenatal clinic. They see 36 patients during the day and, when they leave at 16.00h, Elizabeth is going for her weekend off; having worked 37 hours, she will carry over the three hours owing into next week.

Emma is not called during Friday night but on Saturday morning she arrives at the hospital at 08.00h because one of the continuity patients, Mrs Higgins, is being induced. Emma works for 10 hours and in that time delivers Mrs Isaacs, who comes in second stage, and she also takes the baby when Mrs Higgins has a Caesarean section, and hands it to Mr Higgins for a cuddle.

Joan has spent the day at home and is on call from 18.00h. At 20.00h, the phone rings; it is the beginning of a busy night for Joan. Mrs Jenkins comes in in labour; she delivers at 04.00h. Shortly afterwards, Mrs King comes into the labour ward in labour, followed by Mrs Lo in strong labour. Joan delivers Mrs Lo at 07.00h and then stays with Mrs King, who is plodding along slowly.

By 08.00h, Joan is feeling very tired; she has now worked 44 hours during the week, so she telephones Emma, who comes and takes over from her. Mrs King has a forceps delivery at 11.00h and Emma takes her to the postnatal ward at 12.30h. Having been to see all the continuity patients in the postnatal wards, Emma goes home at 14.00h to await any calls that might come in.

Between them, the continuity midwives have seen 108 antenatal patients and they have delivered 12 patients. Emma has worked 38.5 hours, Joan 44 hours and Elizabeth 37 hours. The hours they have worked over or under will be carried forward to next week and they may find it easier to arrange their timings for a fortnight or three weeks (120 hours). The three midwives will make a point of visiting their patients in the postnatal wards - this can easily be done each time they take a newly delivered mother to the ward.

Three midwives have 21 weeks of holiday between them; they may also have about one week's sick leave each. This means we have available 5,280 hours of midwife time in a year. Of those hours, 1,716 will be taken up with antenatal clinics, which leaves 3,564 hours for labours. If 36 patients are delivered a month, this leaves an average of nearly eight hours for each labour, but it must be borne in mind that some patients will be quick to deliver and sometimes two of the continuity patients will be in labour at the same time; also, of the original 36 who booked, some will miscarry and some will be transferred to total consultant care.

I suggest that the three midwives will be able to look after at least 468 patients antenatally and during labour. The patients will be very happy with the way they are looked after and, in fact, future patients will probably be self selected because once word gets around, many women will choose this way to have their babies.

The system is not for women having shared care with the GP, women having domino deliveries with the community midwife or for women needing specialist care -such as diabetic mothers or those who previously had Caesarean section.

it is a very economical use of midwife time, in a way which can enhance the whole experience of childbirth for the expectant mother and father - and their child. There are obviously times when it will not work smoothly: if Emma is on holiday, Joan has flu and Elizabeth has already done 42 hours work when Mrs Ransome comes into the labour ward in labour, she will have to be delivered by the labour ward staff. But she will have had continuity of care during her antenatal period and Elizabeth will pop in and visit her postnatally in the ward.

For the three midwives, it provides the satisfaction of seeing the patient all the way through; the work will be varied, with days off here and there when no one is in labour; and the midwives will have the great satisfaction of working hard whenever they are on duty - doing real midwifery at its best.

Reference

National Childbirth Trust. (1977). Expectations of a Pregnant Woman in Relation to her Treatment.

November 15, 1979