Continuity of carer and partnership:

Article Outline

• Summary
• Introduction
• Method
• Background
• Continuity of carer and women's satisfaction
• Continuity of carer and partnership
• Continuity of care and midwives’ satisfaction
• Discussion
• References
• Copyright

Summary 

The purpose of this paper was to conduct a critical review of the literature to determine whether there is convincing evidence that continuity of carer is fundamental to midwives forming a partnership relationship with women. Electronic databases and text were searched. The research findings did not support the notion that continuity of carer was a high priority of the women nor was it found to be a clear predictor for women's satisfaction. Continuity of care throughout the childbirth experience was found to increase midwives job satisfaction and autonomy but did not necessarily lead to midwives developing meaningful relationships with women. The lack of research support for continuity of care may be a matter of lack of well-designed studies or it may be a real finding. Further research is required to determine whether continuity of carer is essential to the partnership relationship.

Keywords: Continuity of carer, Partnership, Women's and midwives’ satisfaction

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Introduction 

Continuity of care has been more vigorously promoted in the provision of maternity care in developed countries than in any other health related specialty.¹ Its promotion has been based on the supposition that continuity of care is one of the fundamental principles underpinning woman-centred care (Department of Health, England, 1993), and a midwifery partnership.² Guilliland and Pairman² describe “partnership as a relationship of ‘sharing’ between the woman and the midwife involving trust, shared control and responsibility and shared meaning through mutual understanding” (p. 7). To formulate a midwifery partnership Pairman³ suggests that there needs to be the pre-existence of certain conditions or philosophical beliefs held by the midwife and sometimes by the woman. Guilliland and Pairman² contend that continuity of carer is one of these philosophical underpinnings because the midwife and the woman require time and the opportunity to develop a trusting relationship before the birth of the baby.

What determines continuity of care and continuity of carer, however, remains ambiguous as there are no agreed definitions.⁴, ⁵, ⁶ Continuity of care has been interpreted by some as a shared philosophy of care (continuity of caring) whilst others view it as the provision of care by a known carer or a small group of caregivers throughout the childbirth experience (continuity of carer).⁷ Since the introduction of Changing Childbirth (Department of Health, England, 1993) studies involving continuity of care have accumulated. However, because of the lack of rigorous definitions, and the use of different research designs, comparing these studies and interpreting the findings is problematic.⁶

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Method 

This paper reports on the findings from a critical review of the literature which examined whether continuity of carer could be supported as essential to the partnership relationship. The review included textbooks, the Cochrane Library, and government reports, and references were obtained through database searches utilising CINAHL, MEDLINE, and MIDIRS. The database searches used combinations of the following keywords continuity of carer and care, woman's satisfaction, midwives’ satisfaction, caseload practice, midwife–woman relationship, and partnership. A range of comparative studies, randomised controlled trials, qualitative studies and a systematic review were sourced.

The central focus of this review was to determine if continuity of carer is a necessary pre-requisite to achieving a partnership relationship. Consequently, studies that explored the impact of continuity of care on maternal and newborn clinical outcomes were excluded, as were controlled trials that compared midwifery managed care to obstetric care (where no midwifery care was available).

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Background 

Concerns regarding women's choice in maternity care were identified by the House of Commons Health Committee in the Winterton report,⁸ with some of the current practices of that time questioned.⁹ Many of the recommendations in the Winterton report were addressed by The Expert Maternity Group in Changing Childbirth.⁶ The Expert Maternity Group recommended that women should have continuity of care and carer, and needed to be fully involved in decisions regarding their care. These recommendations were incorporated into a set of objectives for purchasers and providers of maternity care, with a list of 10 indicators of success which were to be achieved within 5 years¹⁰ (p. 70). Continuity of carer/care is included in three of these indicators for success:

The Changing Childbirth guidelines were intended to afford choice, control, and continuity of care for the woman,¹¹ although these terms were not used in the actual report.⁶ Alongside these British reports, reviews of maternity services were also conducted in three states in Australia reinforcing the concept of continuity of care.¹², ¹³, ³³

In analysing Changing Childbirth, Lee⁶ identifies that prior to the publication of the report, no conceptual models of care were developed for testing. Further, no research evidence was provided by the Expert Maternity Group to support the recommendation that: ‘At least 75% of women should know the person who cares for them during their delivery’.⁶, ¹⁴

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Continuity of carer and women's satisfaction 

Four years on, Benjamin et al.¹⁵ echo Lee's concerns⁶ by stating that: “to date there are very few evaluations of the merit of a woman being cared for during labour by a professional with whom a relationship has been formed antenatally” (p. 235).

Some managers of maternity services and practising midwives have also questioned the evidence to support the claim that women want to know the midwife who cares for them during labour and birth.¹⁶ The views of these managers and clinicians are supported by a number of studies which have identified that women do not prioritise continuity of carer for its own sake, but instead place more emphasis on the quality of the care received.¹⁷, ¹⁸, ¹⁹, ²⁰

Drew et al.¹⁷ reported that when asking women following the delivery of their healthy singleton baby to rate by importance 40 items according to their degree of satisfaction with care that: ‘to have a healthy baby’ was ranked the highest. The second most important aspect of care was to have doctors explain procedures in a way they could understand, and the third was to have all questions answered. Being constantly attended throughout labour and delivery was ranked ninth, having a support person at delivery 11th, while being attended by the same midwife throughout the pregnancy was much further down the list being ranked 21st.

In ranking elements of care desired in an ideal system, Lee,¹⁹ 12 years later, found the 32 women in her study ranked the on-call paging system of communication as most important, followed by knowing the labour midwife, and thirdly, having involvement in decision making. However, when these same women were asked to rank the ideal qualities wanted in a midwife, the women ranked ‘is known to you’ at number five. Confidence and trust was rated as the highest quality identified in a midwife; provides safe and competent care rated second; approachability and friendliness third; and involves the woman in choices and decisions fourth.

Measures of satisfaction were compared between women cared for by a known or unknown midwife in a study undertaken by Waldenstrom²⁰ who randomly allocated 410 women to birth centre care during pregnancy. No statistical differences were observed in the women's satisfaction with intrapartum care, or in their experience of labour and birth, when 28% of women delivered by their known midwife were compared with women who had an unknown midwife. Waldenstrom²⁰ concluded from these findings that continuity of carer was less important in a birth centre environment. This finding was attributed to factors such as: the midwives maintained a common philosophy, the small number of carers (the team consisted of 10 midwives), and that all the care was conducted on the same premises.²⁰

Satisfaction with care based on the Changing Childbirth initiative was evaluated by Spurgeon et al.¹¹ utilising a between group design that compared two pilot schemes with that of a traditional model of care. The women in the pilot groups comprised group A who were cared for by one of five named midwives (n=112), and group B who were cared for by any one of five midwives working together as a team (n=103). Group C provided the control group receiving conventional shared antenatal care between their general practitioners and the hospital, and hospital midwives provided the labour and delivery care (n=118). The women in the pilot groups reported higher levels of satisfaction with regard to the quality of midwifery care provided, and a greater sense of involvement and partnership during the antenatal, delivery and postnatal periods, compared to the women in group C who received conventional care. Having a named midwife, however, was not found to be critical to the overall evaluation of quality of care as this preference was reported by just over half the women in groups A and C, and by only one-third in group B. Spurgeon et al.¹¹ concluded from these research findings that the women participating in their study preferred continuous care by a small group of midwives rather than continuity of carer by a named midwife.

Other studies have determined the most important aspects of care for women are that they are involved in the decision making, the information is shared and they feel in control of the childbirth experience.⁹, ²¹ Morgan et al.,²¹ when surveying the effects of different models of continuity on women's satisfaction with care, found that continuity of carer was not a clear predictor of the reported level of satisfaction with care. Instead, 72% (n=247) of the women who completed the questionnaire antenatally and 68% (n=222) postnatally rated feeling in control, involvement in decision making, and being given advice about pregnancy and childbirth, as very important in comparison to continuity of carer.

Similar findings were reported by Lavender et al.⁹ following a survey which explored women's views of factors contributing to a positive childbirth experience. Six hundred and fifteen women were given questionnaires on the second day postpartum, and asked to comment on the negative and positive aspects of their experience, and describe what they believed were the most important aspects of their labour. The women identified the support they received from the midwives and that of their partner or friend as the most important aspect of their labour. Other contributors to a positive labour experience were being in control, participation in decision making, and pain relief.⁹

Several studies¹, ¹⁸, ²² further suggest that whilst many women antenatally placed high importance on being cared for in labour by a midwife whom they had met before, postnatally most women who did not receive this type of care found that it did not concern them. Fellowes et al.,²² in conducting a survey (n=136, 55.7% response rate) to examine women's views on a number of the Changing Childbirth indicators, found that the majority of women (65.4%, n=78) who had not known their carer prior to the commencement of labour felt that this did not matter to them. The women also indicated that it was more important to have good quality care from all health professionals involved in their childbirth experience, and that knowing a named carer throughout the pregnancy and birth was not of top priority.

These findings were supported by research undertaken by Farquhar et al.¹ whilst surveying 1482 women who had consecutive births over a 6 month period, 1077 of whom were cared for by one of seven midwifery teams. Farquhar et al.¹ found that the majority of team women (84%) who had met their delivery midwife previously, reported it made them feel more at ease. However, the majority of women (81%) who had not met their midwife prior to the birth responded by saying it did not affect them one way or another. From these and other research findings relating to intrapartum care, Farquhar et al.¹ suggest that from the women's perspective there were no overall advantages in being delivered by a known midwife.

Despite problems with definition and the different research designs adopted, much of this literature supports the belief that women do not focus on a system or model of midwifery care, such as continuity of carer. Rather, women focus on the content of the care delivered preferring, for example, the sharing of information and involvement in decision making. Table 1 provides a summary of the studies reviewed examining continuity of carer and women's satisfaction.

Table 1. Summary of studies examining continuity of carer and women's satisfaction

Authors	Sample size	Study design	Results
Drew et al.17	183 women	Comparative ranking	‘Being attended by the same midwife throughout labour and delivery’ was ranked at 21
	52 obstetricians	Questionnaire @ 18–96h postpartum
	28 midwives
Lee19	32 women	Descriptive	In ranking qualities wanted in a midwife ‘Is known to you’ ranked fifth
	12 midwives	Interviewed postpartum
Waldenstrom20	410 women	Descriptive survey	Knowing the midwife prior to the birth did not effect reported levels of women's satisfaction with intrapartum care
		Questionnaires @ 38 weeks gestation and 8 weeks postpartum
Spurgeon et al.11	112 women pilot A	Retrospective between groups	Pilot groups reported higher levels of satisfaction with regard to the interpersonal relationships with women
	103 women pilot B	Questionnaire 6 weeks postpartum
	118 women control C
Morgan et al.21	247 women antenatally	Survey	Continuity of carer did not predict level of women's satisfaction
	222 women postpartum	Questionnaires @ 36 weeks gestation and 2 weeks postpartum
Lavender et al. (1999)9	615 women	Survey	Support of midwives and partner, but not continuity of care, was considered crucial to the women having a positive birth experience
		Questionnaires @ 2 days postpartum
Fellowes et al.22	136 women	Survey	Having a known midwife is not a top priority for women
		Questionnaires @ 2 weeks postpartum
Farquhar et al.1	1482 women	Survey	Women cared for in a team midwifery scheme identified no overall advantages in continuity of care
		Questionnaires @ 1 week postpartum and Interviews postpartum

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Continuity of carer and partnership 

Most of the reviewed studies have assessed women's satisfaction with continuity of carer and care. However, few studies have discussed the type of relationships women form with midwives within this context.

In four studies, where the majority of women experienced continuity of carer, it was reported that the women formed partnerships with midwives²³, ²⁴ or developed relationships described as friendships.³, ¹⁶ These reports could suggest that it might be easier to form a partnership when continuity of carer has been provided.

In exploring women's perceptions of care beyond assessing levels of satisfaction, Coyle et al.²³ interviewed 17 women between 2 and 4 months postpartum who had experienced care in both birth centre and hospital settings. To ensure the women in the birth centre model of care had received care from a known midwife during their labour and birth, the women had to be cared for by a midwife who had performed at least two of their antenatal visits. The participants described the type of relationship they had with their midwives in the birth centre setting as a collaborative relationship. Coyle et al.²³ defined this as a ‘partnership’ as the relationship was characterised by equality with the midwives, and the women were the primary decision makers. However, when the same women described their interactions with medical practitioners and midwives in the hospital setting many perceived a sense of medical domination in the relationship.

Women who experienced continuity of carer through a partnership caseload practice have also been found to form relationships with their midwives that challenged the traditional models of care.¹⁶ The partnership caseload practice model consisted of community based midwives who worked together as partners, sharing a caseload of women for whom continuity was provided from pregnancy through to the postnatal period. The women who experienced the partnership caseload model of practice were found to commonly refer to their relationships with their midwives as friendships that were personal and intimate, and a number felt ‘in control’ and empowered by their birth experiences. Walsh¹⁶ does, however, discuss that due to selection bias (five of the 10 women had homebirths), the generalisability of these research findings were compromised.

Friendship was also the term used to describe the relationship the six women participating in Pairman's³ research developed with their independent midwives. Pairman²⁵ suggests that implicit in these descriptions of friendship were the characteristics inherent in the midwife–woman relationship, which include knowing each other, equality and trust.

Tinkler and Quinney²⁴ in exploring the influences of team midwifery on the midwife–woman relationship compared two pilot groups of women receiving a team approach to care with a group of women who received traditional midwifery care. Individual interviews were conducted postnatally with eight women in the core pilot group, whilst group interviews were held with 14 women antenatally and 16 women postnatally in the peripheral pilot group (n=30) and the traditional ‘no change’ group (n=30). Tinkler and Quinney²⁴ found that the women who received team midwifery care appeared to have closer relationships with their midwives than those women who received the traditional style midwifery care.

Continuity of carer, however, was not found in all of these reviewed studies to lead to a partnership relationship. In investigating the relationship of midwives and women, Fleming²⁶ interviewed 12 midwives working in independent practice in New Zealand and 20 women who sought care from these midwives. The majority of the women were multiparous and all were attending independent midwives for the first time. Data was collected through a series of up to six semi-structured interviews lasting on average 1–2h. These interviews were supplemented with video-taped analysis of the women's births and the midwives documenting their thoughts in journals. The midwives in Fleming's²⁶ research all discussed the concept of partnership as a basis for their practice. However, the women for whom this care was provided presented a different viewpoint instead perceiving the midwives as part of the medical fraternity. To portray a commonly held view by the women Fleming²⁶ cited the words of one woman who described the midwives as the ‘medical half’ of the relationship (p. 10). This point was further illustrated by another woman who reported that the care received from her independent midwife was no different to that of the obstetrician engaged in the previous pregnancy. Fleming²⁶ concluded from these findings that there was incongruence between the beliefs of the midwives and the women, and that the women did not achieve a partnership relationship.

Table 2 provides a summary of the studies reviewed examining continuity of carer and partnership.

Table 2. Summary of studies examining continuity of carer and partnership

The literature reviewed so far explores the women's point of view, but there are other participants in the relationship – the midwives. How then do midwives perceive working in continuity of care models and how does this impact on their relationship with women? A review of literature found a limited number of studies that investigated midwives’ satisfaction with working in continuity of care models.

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Continuity of care and midwives’ satisfaction 

Midwives providing continuity of care are reported as experiencing increased autonomy and job satisfaction, but this often came at a cost to their personal lives²⁷, ²⁸, ²⁹ due to either needing to be continuously available or providing long on call cover.²⁹, ³⁰

Stress and frustration were acknowledged by midwives participating in Sandall's²⁸ research and attributed to their inability to develop meaningful relationships with the women for whom they cared. These findings largely accord with Todd et al.³⁰ and Shallow's³¹ evaluation of team midwifery schemes. Of the 50 community midwives working in teams and 30 hospital-based midwives participating in Todd et al.³⁰ study, only 6% reported that they always developed a relationship with women, and less than 20% perceived an improvement in care since the introduction of the team approach. Shallow³¹ further noted that when midwives were integrated from community and hospital settings to work in teams of up to 20 midwives that continuity of care did not improve, nor did it improve the midwife–woman relationship.

On the other hand, Stevens and McCourt²⁹ found when evaluating midwives experiences of working in a caseload practice that a major source of satisfaction for the midwives came from the relationships they were able to form with the women. However, it was acknowledged that it was tiring for less experienced midwives to care for ‘difficult’ or demanding women, and that it took time and skill for midwives to master achieving the right balance to act as a facilitator rather than creating a relationship of dependency.

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Discussion 

The relationship between a woman and a midwife is at the heart of midwifery practice.³² Yet of the five studies reviewed on continuity of carer and partnership only two explored the types of relationships formed by obtaining data from both the women and the midwives,³, ²⁶ the remaining three studies only investigated the views of the women. These studies generally used qualitative approaches which effectively explore the views of the participants and identify some important issues, but these would need further research before generalisation to other practice settings was appropriate. To compound the problem both Fleming²⁶ and Pairman's³ research was conducted with independent midwives in New Zealand but their findings were opposing.

Taking into consideration that eight of the studies reviewed were interested in determining women's satisfaction with continuity of carer and care, seven of the studies questioned the women on only one occasion in the postpartum period and did not collect data throughout the woman's childbirth experience. The times of the data collection also ranged from 18h following birth to six weeks postpartum (refer to Table 1). Although these studies had relatively large numbers of women participants (n=32 to 1482) the research designs varied. Four were surveys.¹, ¹⁷, ²¹, ²² Two were part of large randomised controlled trials.⁹, ²⁰ However, exploring the association between continuity of carer and women's satisfaction with care was not the primary focus of these two projects. Waldenstrom study,²⁰ for example, was designed for a randomised controlled trial of birth centre care. One was a small descriptive study comprising 32 women and 12 midwives¹⁹ and another a retrospective comparative study.¹¹

It would appear from the findings of the studies presented in this review of literature that continuity of carer was not a clear predictor of women's satisfaction, and that the women did not focus on the model of care provided but instead on the content of the care provided. However, due to the small number of studies undertaken and the various methodologies employed, further research is required to explore the types of relationships women form with midwives. These studies need to include both participants in the relationship – the women and the midwives.

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