What Happened To Continuity Of Care?

A small pilot scheme aiming to improve maternity care has been axed. It’s left some pregnant women suddenly without the care they were expecting and wondering where to turn now. It also raises questions for maternity services nationwide.

It was announced this week that Neighbourhood Midwives is to close. The group operated an NHS continuity-of-care pilot scheme in part of London since 2016. They also offered private midwifery care packages. The pilot gave women the opportunity to get all their antenatal, birth and postnatal care from the same pair of midwives who they could get to know and build a relationship with.

Its the type of care that has been called for over and over again for maternity services. It’s also one that I have both benefitted from and suffered from a lack of.

There was no continuity of care in my first pregnancy. Antenatal appointments were with various midwives at my GP surgery, I laboured with a string of strangers, sometimes sharing a midwife with another labouring woman. After the birth I never saw the same person twice, everyone gave different advice when I was struggling with breastfeeding and no one picked up on health issues I’d end up living with for months and years afterwards.

Before my subsequent babies I researched furiously, looking for a way to get better midwife care. I investigated independent midwives (including Neighbourhood Midwives) and eventually managed to beg myself a slot with an NHS caseload team. The difference with those babies, particularly in the postnatal period, was huge.

Feedback on the service provided by Neighbourhood Midwives has apparently been very positive too, so why has the NHS decided to ditch them?

No really – any idea?

The current information from Waltham Forest CCG (the body who commission NHS services in the area) is:

…significant challenges around coordinating business planning and the commissioning timetable have necessitated the service’s closure.

Which doesn’t really tell us a lot except that it’s probably got something to do with money. I’ve asked Waltham Forest CCG if they will give more information, but as yet I’ve not had a response.

I really really hope there is a response.

Continuity of care has been on the maternity services wish list for years. Sometimes it can feel a bit like the answer given for everything: Unwanted interventions? – More continuity.  Poor outcomes for Mums and babies? – Continuity of carer. Concern about breastfeeding rates? – Continuity!

There may well be something in those responses (although continuity alone isn’t going to solve all our problems), but shouting for continuity without actually getting it won’t help women. The shouting has been going on or years and yet still the reality for most women doesn’t match up to the desire, why? If there are lessons to be learned in Waltham Forest we need to learn them, even if they turn out to be unpalatable.

I can imagine a couple of issues with groups such as Neighborhood Midwives, they are both essentially related those most precious NHS resources: time and money.

Caseload midwives look after fewer mums, they give them more time and often travel to them rather than the other way around. They each take on a few new women per month so that there is a really good chance that when one of those women goes into labour the midwife won’t already be looking after another labouring woman. It’s a wonderful thing, but I’m guessing the midwife-per-mum cost is higher than for standard care.

There is also the demand on midwives to be available at unpredictable times. Births rarely slot nicely into office hours or even pre-arranged shift patterns. I’ve heard several midwives say that, although they would love to work in a caseload team, it’s simply impossible because of their own young children.

Whether it was these issues or something else entirely that put an end to the Neighbourhood Midwives, we need to know. Many people want continuity but we need it to be a realistic option, and definitely not just a pipe dream that can be used to quieten more difficult questions.

We also need to ensure that the calls for more continuity aren’t just answered with token services open only to a lucky few. During my (very expensive, very middle class) NCT classes I was told to play the system, claim to want a home birth even if I didn’t as that was the way to get a caseload midwife*. The Neighbourhood Midwives pilot could only take women having midwife-led care, and so presumably excluded anyone deemed high risk whose care was officially led by doctors. Their homebirth rate was 52% compared to a national homebirth rate of 2.1% which suggests their clients probably weren’t representative of the general population. With my subsequent pregnancies, I had no hope of ( or desire for) a homebirth as I was high risk and planning a C section. I researched and argued my way into caseload care, but I’m conscious of the privileges that enabled me to do that.

If continuity has the many benefits that are claimed for it, then it surely should be available to all and not reserved for a particular group? Box ticked, move on, never mind everyone else?

Understandably the Neighbourhood Midwives team have said that their focus right now is making sure that all the pregnant women currently with them can be found suitable alternative care. My heart goes out to those women. Once that work is done I hope there will be a long, hard and public look at what happened and that ( if we can take anything positive from this) that will provide information and lessons to help improve maternity care for all expectant parents.


PS. I decided against Neighbourhood midwives and pretty much every independent midwife I found in my online searching in part because they all seemed to offer unproven or downright disproven alternative treatments. This ranged from linking to outside companies offering services like placental encapsulation to midwives detailing with pride their “qualifications” in homeopathy and energy healing.  There’s a whole other blog post in that, but regular readers will be aware that it’s not exactly my thing…

PPS. I’ve been toying with killing the blog off entirely. Somehow despite not working now I seem to have even less time for it (oh yeah, 3 kids, that’ll be it). But I may just bang out the odd post like this when I need to get something off my chest and a twitter thread would just be a bit much. Plus it’s a lot cheaper than therapy.

*As it turned out it was too late to do this by the time our classes started as all the teams were fully booked, no doubt it was pure coincidence that the NCT teacher also happened to run a group of private midwives who could also offer continuity, for a fee.


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