Implementing improved maternity care on the front line

Setting up a completely new care pathway in a hospital and then testing in a pilot is no mean feat. But following an influential review on continuity models of midwife care, that is exactly what Professor Jane Sandall did. The work, which took place at Lewisham Hospital, was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care South London (CLAHRC). 

A Professor of Social Science and Women's Health and a midwife, Jane Sandall is an NIHR Senior Investigator who leads the maternity and perinatal mental health theme of the NIHR Applied Research Collaboration South London. She explains: “A particular attribute of CLAHRC work is to address local health needs, to address a research gap and to co-develop the work with local partners. Back in 2013 we had just published a Cochrane Review on continuity models of care that showed that there was a reduction in preterm birth and Lewisham Hospital were very keen to support the development of this model of care.”

The 2016 update to the Cochrane Review had shown that women who received midwife-led continuity models of care were 24 per cent less likely to experience preterm birth, and additionally 16% less likely to lose their baby overall and 19 % less likely to miscarry. At the time, Lewisham’s public health department was concerned about preterm birth rates in the area and the local Clinical Commissioning Group also put some money into the development of the new model of care.

Midwifery continuity of care means a woman will have a named and a backup midwife from the same team caring for them during their antenatal period, labour, birth and postpartum period. This allows a relationship to develop, so women feel that they have the support of someone who knows their medical history and this in turn may increase confidence and reduce levels of stress. Women are more likely to be open about lifestyle choices and also to trust advice that is given by their midwife. 

Preterm birth, where a baby is born before 37 weeks of gestation, is linked to adverse outcomes including survival, quality of life, psychosocial effects on the family and increased health care costs. Professor Sandall and the team wanted to test whether the model of care the review had suggested could improve outcomes would be feasible and effective in practice for women who were at increased risk of preterm birth. 

POPPIE — the protocol for a randomised controlled pilot trial of continuity of midwifery care for women at increased risk of preterm birth — was a pilot trial of 350 women in Lewisham. The women were randomised to receive either continuity of midwife care or standard care from the time of recruitment, through their antenatal care, labour, birth and the postnatal period, in hospital and community settings and in collaboration with a specialist obstetric preterm birth clinic, when required. They were followed up until 6–8 weeks after birth.

This was the first study to provide direct evidence regarding the effectiveness, implementation and evaluation of a midwifery continuity of care model and rapid access to specialist obstetric services for women at increased risk of preterm birth. The midwife who managed the trial, Cristina Fernandez Turienzo, has been awarded an Iolanthe Midwifery research fellowship to write up her PhD on POPPIE.  

Professor Sandall says: “It was a really interesting process to see the relationship between Cochrane, the policy and the research, and how each one informs the other and starts to take shape in reality. Since the trial, the experience of this has been used to scale up six more models across Lewisham and Greenwich NHS Trust and there are other Trusts trying to set up in this way too. I think that without the support from us from an academic point of view and from the Clinical Commissioning Group it would have been much more difficult.”

During the trial, the Better Births report into improving outcomes of maternity services in England was published and this advocated that more women in England should have the continuous model of care. 

Implementation guidance has been written with the Royal College of Midwives and NHS England have generated implementation support and training. Professor Sandall explains that they drew on the experience of the midwives and managers in South London: “We went to 57 trusts talking with managers and front-line workers about how you can implement this model in a way that is sustainable. There’s nothing like having someone who has been managing a team and providing continuity of care for years to answer the questions that midwives are concerned about - how they achieve high levels of continuity in the real world.” Crucially, the guidelines: “include some measurements that send the strong message that unless you do it in the right way you won’t achieve the benefits and outcomes.”

Professor Sandall continues: “The million-dollar question is, what is the mechanism for the improvements in outcomes we see with the continuity model? Is it acting as a safety net so women get a better quality of care? Is it reducing stress as women feel safer? This does seem to have an impact on some preterm birth rates, but not all causes of preterm birth. There is a global community working on this area and trying to work out what these mechanisms are.”

The latest work in the Applied Research Collaboration (ARC) South London is looking in more detail, particularly at the impact on women with multiple disadvantage and Black Asian and Minority Ethnic women. The NHS 10-year plan focuses on improving outcomes for this group of women and suggests scaling up continuity of care to support them. The team is testing what sort of models and care work to improve outcomes for women with multiple disadvantage, particularly if they have perinatal mental health problems. 

Professor Sandall concludes: “It’s great to see policy happening as a result of our work but from my point of view the important thing is what happens on the front line, which is why the trial was important.  A lot of our work now is on implementation of these models and how you support that.”