Report identifies range of challenges with implementation of Midwifery Continuity of Carer

A new report from researchers at City, University of London has identified a range of challenges for the implementation of the Midwifery Continuity of Carer (MCoC) model at the system, organisational and professional levels.

Funded by NHS England, the independent evaluation report found that midwives working in continuity teams loved their work and felt they were providing better quality of care, but strain on services and staff shortages meant they were often called to do extra work to cover service gaps or given excessive caseloads, which made this way of working less sustainable.

Led by Professor Christine McCourt, Professor of Maternal Health in the Centre for Maternal & Child Health Research at City, University of London, the evaluation took place between January and April 2023. The researchers used a mixed methods approach including a national online survey of service and implementation leads with follow-up interviews and case studies in three Trusts to identify the barriers and enablers to implementing MCoC with the aim of informing future implementation plans.

MCoC formed a main plank of the 2016 national maternity policy ‘Better Births’ because it has been shown in gold standard research to improve clinical outcomes, quality and experience of care: women who received continuity of carer in midwifery settings felt better supported and informed, especially for those in more vulnerable situations.

The key findings of the report are as follows:

• Midwives who are given effective support to adapt to working in this model found their work more rewarding and did not want to go back to working in previous care models.
• The level and quality of implementation of midwifery continuity teams were found to be very varied. Services where this worked well tended to have a good level of senior management support, including NHS Trust Boards, time to plan and transitional funds. Although this way of providing care has been shown to be cost effective, services needed to have sufficient midwifery staffing in place to manage the change well. Implementation leads also needed access to reliable data systems to identify workforce implications and demonstrate these to decision-makers.
• In contrast, in some services senior staff member’s understanding of the model was limited and the midwives leading change lacked change management experience and received little support for this. In some services there was a lack of understanding or even dismissal of the evidence, which undermined the process, leading to a lack of effective support. Adaptations of the model (such as limiting it to those with particular conditions or birth plans, not sticking to recommended case load size, or not giving teams the flexibility to manage their caseloads) reduced the workability or effectiveness in practice.
• Midwives working in continuity teams loved their work and felt they were providing better quality of care, especially for more disadvantaged women, but strain on services and staff shortages meant they were often called to do extra work and shifts to cover service gaps, which made this way of working less sustainable.
• Some midwives lacked confidence and were worried about adapting to a different way of working, or working across different areas after a long career or working mainly in one. Good quality and supportive leadership and preparation were found to be vital to support midwives, as well as buy-in and support from other maternity professionals, which was not always present. As one manager said – this is about the whole maternity service, not just about midwifery.
• Managers said that even though this model of care was recommended in national policy, targets were important to convince decision-makers and NHS Trust Boards to support the change, but they needed to be realistic and manageable ones. Some Trust Boards had moved to simply disband well-functioning teams once targets were removed, leading to demoralisation.

Professor McCourt said:

“A lack of understanding of the evidence, lack of institutional support for change, and services implementing variations of the model which don’t work in the same way in practice, compounded by a national shortage of midwives, has stifled implementation in many NHS Trusts.

“While our report has identified a range of challenges for implementation at the system, organisational and professional levels, we found that midwives working in continuity of carer teams found their work more professionally rewarding and spoke of the improved quality of care they could provide, especially in communities with more disadvantage.

There is gold-standard evidence that MCoC has significant clinical benefits, improves women’s experiences of care and is professionally satisfying for midwives. But despite national policy drivers since 2016, implementation has been variable nationally and often limited. We also found that senior professionals and managers in some services lacked an understanding of the evidence and particularly the significant clinical benefits as well as patient experience.