Implementing continuity of midwife carer – just a friendly face? A realist evaluation

Abstract

Background: Good quality midwifery care saves the lives of women and babies. Continuity of midwife carer (CMC), a key component of good quality midwifery care, results in better clinical outcomes, higher care satisfaction and enhanced caregiver experience. However, CMC uptake has tended to be small scale or transient. We used realist evaluation in one Scottish health board to explore implementation of CMC as part of the Scottish Government 2017 maternity plan.Methods: Participatory research, quality improvement and iterative data collection methods were used to collect data from a range of sources including facilitated team meetings, local and national meetings, quality improvement and service evaluation surveys, audits, interviews and published literature. Data analysis developed contextmechanism-outcome configurations to explore and inform three initial programme theories, which were refined into an overarching theory of what works for whom and in what context. Results: Trusting relationships across all organisational levels are the context in which CMC works. However, building these relationships during implementation requires good leadership and effective change management to drive whole system change and foster trust across all practice and organisational boundaries. Trusting relationships between midwives and women were valued and triggered a commitment to provide high quality care; CMC team relationships supported improvements in ways of working and sustained practice, and relationships between midwives and providers in different care models either sustained or constrained implementation. Continuity enabled midwives to work to full skillset and across women's care journey, which in turn changed their perspective of how they provided care and of women's care needs. In addition to building positive relationships, visible and supportive leadership encourages engagement by ensuring midwives feel safe, valued and informed.Conclusion: Leadership that builds trusting relationships across all practice and organisational boundaries develops the context for successful implementation of CMC. These relationships then become the context that enables CMC to grow and flourish. Trusting relationships, working to full skill set and across women's care journey trigger changes in midwifery practice. Implementing and sustaining CMC within NHS organisational settings requires significant reconfiguration of services at all levels, which requires effective leadership and cannot rely solely on ground-up change.

Better maternity care pathways in pregnancies after stillbirth or neonatal death: a feasibility study

“…Previous studies to increase midwifery continuity, mainly in low-risk pregnancy, have focused on case-holding models which required significant workforce flexibility including 24-h on call [ 12 ]. These models often proved difficult to sustain beyond research or small-scale contexts in the UK [ 36 , 37 ]. The role of care- coordinator also required changes in practice from the midwives, although they were not asked to be on call for births, most volunteered to be involved and were highly invested in delivering the intervention as planned.…”

Exploring the uses of virtues in woman‐centred care: A quest, synthesis and reflection

“…Prudence is a governing virtue, suggesting that an agent would be of merit to arrive at pragmatism. An agent who leads, generates meaning, who casts light on woman-centred care points of view and actions, who shifts the direction of ideas in maternity services and who safeguards the essence and importance of womancentred care (Deering et al, 2020;McInnes et al, 2020).…”

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice

“…The implementation of QCP-M in clinical sites is influenced by nurses and midwives, whose local knowledge, values, beliefs, and individual characteristics determine their interaction with the intervention. Awareness of this facilitates the successful implementation of the QCP-M within the clinical setting [34,39,41,44,45,51,54,[58][59][60][61].…”

“…Clinical sites recognise and respect the knowledge [34,39,41,45,54,58,61], beliefs [36,44,54,61], and values [45] of nurses and midwives and their unique individual characteristics [41,51,[58][59][60], thereby facilitating the promotion and adoption of quality improvement initiatives [61]. QCP-M introduced into clinical sites that have supporting education and training functions, and champions/implementation leads to support them, facilitate staff engagement with evidenced-based practice programs, leading to their successful implementation and adoption [32][33][34][38][39][40][41][42][43][44]48,53,54,61].…”