Over many years, my friend Sheila Kitzinger and I talked about the importance of women receiving care from one or a small group of midwives whom they could get to know and trust over time, which became known as continuity of carer. Sheila supported me in the early days of development of continuity, in what was often a very political battle. She had a clear understanding of the benefits of continuity of relationship between women and midwives; she spoke and wrote, till the end of her life, about the need for every woman to have a midwife she could get to know and trust for her care before, during and after birth. It seemed appropriate, then, that the inaugural research seminar in October 2015 of the Sheila Kitzinger Programme at Green Templeton College, Oxford, involved 2 days of presentation of the evidence and intensive discussion around continuity in midwifery-led care.
The Sheila Kitzinger Programme was established in honour of the life and work of Sheila, a social anthropologist, who died in April 2015. She was a high-profile feminist campaigner across a broad range of issues, and was passionate about women and childbirth.
The aim of this seminar was to help understand how the NHS might implement evidence, scale-up and sustain relational continuity in maternity care, and expand access to these services. The seminar involved health service leaders, academics and representatives from a range of lay groups. The report, Relationships: the pathway to safe, high quality maternity care, will soon be published online (www.clahrc-southlondon.nihr.ac.uk/news/2016).
Despite the compelling evidence of the benefit to women and their families of getting to know their midwife, and support in UK policy, few women have access to continuity of carer. Relationships: the pathway to safe, high quality maternity care gives a comprehensive review of current evidence and the benefits to women, their families and the NHS, of relationship-based continuity. It is clear from the evidence that it is only relational models of health care that have been shown to impact on clinical outcomes. These relational models mean a supportive relationship between an individual and their care provider that ensures care, partnership and advocacy. It is possible to provide this continuity through various models, allowing tailored responses to individual services and communities.
The report's description of the mechanisms that make relationship continuity work will be important to those scaling up or developing services to provide relationship-based continuity of carer. This understanding helps move beyond simply making structural change, and will guide process and cultural development as well as education and training.
Many midwives, in the UK in particular, will have experienced setting up or working within continuity of care models that were not sustained, or have been closed despite success. The report provides details of the commonly recurring desirable features of successful implementation and scale-up to ensure effectiveness, sustainability and good working conditions for midwives.
Successful examples illustrate what makes relationship-based care successful, give a fuller understanding of what makes maternity services high-quality and safe, and describe how the approach might work in different ways. Barriers to development and sustainability are described, along with approaches to facilitation.
The complex and fragmented maternity care that is the norm for many women in the UK has been an important factor in some of the problems that have occurred in maternity services in recent years. The report highlights clearly the importance, if we are to provide safe services, of bridging the gaps through continuing relationships, embedded in appropriate organisation and effective services, with enabling rather than controlling support, as part of an effective system of care and a supportive culture. Our NHS systems, including integrated hospital and community care and a strong midwifery profession, offer us many advantages in scaling-up relationship-based continuity of carer. As well as being woman-centred, the care needs to be midwife-friendly. This includes adequate educational and professional development.
The recent National Maternity Review (2016) in England reinforces the critical importance to safe, high-quality maternity services of continuity of carer. It is high time the NHS enabled the majority of women to receive care based on relationships between women and their midwives, and to take continuity of midwifery care from the fringes to the mainstream: relationships developed over time are fundamental to midwifery care that is safe, high-quality and transformative.