By Caroline Flint

A new maternity care scheme in Riverside gives women continuity of care and reduces hospital costs

For many years women have complained about the fragmentation of their care and the lack of carers during pregnancy, labour and the puerperium.

Micklethwaite, Beard and Shaw 1978⁵

`She would like, if it were possible, to have someone around her during labour who had given her some antenatal care.'

Short Report 1980²
`I think this is what women complain about most: they do not have continuity of care which they want very much during their antenatal visits but certainly during labour and delivery.'

`We recognize the difficulties of providing continuity of care throughout pregnancy and labour but consider that a measure of it can be obtained by better organization.'

MSAC 1982⁴
`Continuity of care. It is important that the woman should be able to build up a relationship of trust with the staff she meets, and efforts should be made to involve the same group of staff at each visit.'

RCOG 1982⁷
`It has been suggested to us that women should have the same midwife to attend them in labour as in the antenatal period. We consider this continuity of care to be an ideal aim and it may be possible in some circumstances.'

Parents Magazine 1986⁶ (9,000 replies) `Good communication between parents and the medical staff were helped where women saw the same doctor and midwife regularly ... most mothers saw different people at almost every antenatal visit and were delivered by total strangers. While full of praise for the care they received, many women wished they could have had more continuity of care through pregnancy and beyond.'

Now, at last they are being listened to. The obstetricians and midwives of Riverside Health Authority from January 1989 are starting far-reaching changes in the way they deliver maternity care, which they see as the spearhead for future patterns of maternity care in the United Kingdom.

The new scheme

Under the new scheme most maternity care (except delivery) will take place either in, or near the woman's home. Once she has been and referred her pregnancy to her GP, the woman's next brush with the maternity services will be when she receives a letter detailing the team of six midwives who will care for her throughout her pregnancy, labour and puerperium. She will be given a photo of `her' midwives and a date and a time when one of the midwives will visit her at home to take her obstetric history, a blood sample and plan the schedule of visits she will have during her pregnancy. Sometimes her antenatal consultation will be with the midwife team, sometimes with her GP and

The woman will either be seen at home or at a local health clinic, where her obstetrician will also visit occasionally. Here she will also attend parentcraft classes and after the baby is born, mother and toddler groups, breast feeding clubs and nutritional meetings, such as `Eating healthily on a budget' or `Healthy eating without cooking', because the teams will be working closely with a dietician.

When the woman thinks she is in labour, having got to know the six midwives in her team during pregnancy, the woman will bleep the midwife team and whichever of the midwives is on call will answer the bleep. The usual practice will be for the midwife to visit the woman at home and assess the progress of the labour. Once it is appropriate for the woman to be transferred to hospital she and the midwife will set off with the partner, relatives and/or friends, probably by ambulance, but by car if available.

Once the midwife and the mother have arrived at the West London Hospital, the midwife will continue care - she has been writing the woman's notes (which the woman will have been carrying since the beginning of her pregnancy) - with referral to the medical staff if necessary.

The midwife will stay with the mother during labour and deliver the baby - the time needed should not be too great if she has judged the progress of labour well. According to the work of Klein³, when women are assessed in early labour at home they spend less time in the delivery ward, have more normal deliveries and need less analgesia than women who spend most of their labour in the labour ward.

It is thought that the benefits for women will be that they will enjoy being able to get to know their midwives. Their reactions are being assessed with the use of the Edinburgh Postnatal Depression Score at approximately six weeks following delivery and the results will be compared with those obtained from women prior to the start of the scheme.

The midwives' job satisfaction levels are being assessed with a questionnaire which was given out to all midwives prior to the inception of the scheme. This will be distributed again once the scheme has been in operation for about nine months to see if there are any changes in attitudes of the midwives. It is interesting that although no advertisements have yet been put out for midwife team members, every post brings letters from midwives all over the United Kingdom applying for a position in one of the teams. The midwives, it seems, can hardly contain themselves in their eagerness to start working in this way.

An example of one off duty is shown in Figure 1. The off duty will be planned for a year in advance and there will nearly always be a member of the team on holiday so that usually there will be five midwives working at any time; the midwives will aim to book six new women each week, to deliver six women each week and give postnatal care for the six women who deliver each week.