Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians

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Women and Birth xxx (2019) xxx–xxx

Contents lists available at ScienceDirect

Women and Birth journal homepage: www.elsevier.com/locate/wombi

Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians Cathy Stylesa , Lauren Kearneya,b,* , Kendall Georgeb a b

Women and Families Service Group, Sunshine Coast Hospital and Health Service, Australia School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 19 December 2018 Received in revised form 14 August 2019 Accepted 15 August 2019 Available online xxx

Problem: Despite high quality evidence supporting midwifery continuity of care, access to this model is limited in many parts of Australia and internationally. Background: The models of care provided to women have a strong influence on their perinatal experience and clinical outcomes. Midwifery Continuity of Care (CoC) is arguably the most significant factor in enhancing women’s clinical outcomes during child-bearing and facilitating a positive childbirth experience. Health system change is required, yet little literature has detailed the actualisation of this in the context of upscaling midwifery CoC. Research question/aim: This study aimed to explore the perceptions and experiences of midwifery and obstetric staff during the implementation and upscaling of midwifery CoC within a regional hospital and health service in coastal Queensland, Australia. Methods: A single-site, qualitative enquiry. Obstetricians and midwives participated in semi-structured interviews or focus groups at two-time points: within 2 months of introduction of the CoC service (obstetricians n = 6; midwives n = 15); and 2-years after implementation (obstetricians n = 5; midwives n = 17). Data were analysed thematically. Findings: Four key themes and several categories were generated from the data: hopes and expectations; clinical and practice changes; organisational and structural change; and, future directions. Discussion: Organisational culture, structural change, communication processes and collaborative relationships can be used to inform future scale-up and sustain midwifery caseload care. Specifically, communication, inter-disciplinary collegial relationships, and managerial support are crucial to the sustainability and ultimate upscaling of caseload midwifery care. Conclusion: System change is challenging, but in order to improve access to midwifery CoC is necessary. © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Keywords: Midwife Continuity of care Models of care Organizational change Qualitative research

Statement of significance Problem  Despite high quality evidence supporting midwifery continuity of care, access to this model is limited in many parts of Australia and internationally.

* Corresponding author at: Lauren Kearney, School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia. E-mail address: [email protected] (L. Kearney).

What is already known  Women receiving midwife-led continuity models are less likely to experience regional analgesia, instrumental vaginal birth, preterm birth and fetal loss.  Many women do not have access to a known midwife during the perinatal period. What this paper adds  Successful implementation and upscaling of Continuity of Care was facilitated through: supportive midwifery and obstetric leadership; communication; inter-disciplinary collaboration; and, rostering flexibility (between midwifery management, obstetricians, core and caseload midwifery staff).  Issues that arose may have been avoided if a clearer implementation strategy was in place prior to commencement.

http://dx.doi.org/10.1016/j.wombi.2019.08.008 1871-5192/© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: C. Styles, et al., Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.008

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1. Introduction The models of care through which maternity services are provided to women have a strong influence on their perinatal experience and clinical outcomes. Within Australia, midwives predominantly work within either the traditional health system model (known as Core in this study), whereby they provide midwifery care to women they may or may not have met before, and work rotational shifts to service clinics, birthing services, postnatal wards and early discharge programs; or in midwifery Continuity of Care (known as Caseload in this study), whereby women have a primary midwife assigned to them throughout pregnancy, birth and the early postnatal period.1 Midwifery Continuity of Care (CoC) is arguably the most significant factor in enhancing women’s clinical outcomes during child-bearing and facilitating a positive childbirth experience. The most recent systematic review comparing midwife-led with other models of care for childbearing women found that women receiving midwife-led continuity models were less likely to experience regional analgesia, instrumental vaginal birth, preterm birth and fetal loss.2 Whilst they were also more likely to experience a spontaneous vaginal birth, they were not more or less likely to give birth via caesarean section or have an intact perineum.2 Not only are women’s physical outcomes affected by midwifery CoC, recent studies also suggest that it has a moderating effect on prenatal stress and postnatal maternal wellbeing.3 The Queensland Flood study found a significant interaction between maternity care type and subjective stress, with continuity of midwifery care having a ‘buffering’ effect when increasing objective and subjective stress was measured; this was sustained until six weeks postpartum.3 Women have also expressed a preference for care by a known midwife. Perriman and colleagues conducted a robust systematic review and meta-synthesis of women’s perspectives on continuity of midwifery care.4 Thirteen qualitative studies (2006–2016) were included in the synthesis from high-income countries (including six from Australia). The midwife-woman relationship was identified as the key conduit through which trusting, respectful and empowering maternity care is provided; this was highly valued by women.4 Two publications arising from the multi-centre, randomised controlled trials (RCTs) conducted in Australia in recent years also found women’s experience of continuity of midwifery care to be highly valued and positive.5,6 Allen and colleagues5 undertook a thematic analysis on the ‘free text’ participant responses (n = 901) collected as part of the M@NGO RCT to identify how women allocated to caseload care characterised their midwife, and how the midwife’s personal attributes affected women’s satisfaction with care. Whilst women in both groups (caseload and standard care) identified positive midwifery attributes (informative, competent and kind); a theme of ‘above and beyond’ was more frequently identified by the midwifery CoC participants. Going ‘above and beyond’ gave women a sense of empowerment and ‘endorphic’ reaction to their care – suggesting that midwifery CoC equips midwives to provide responsive, woman-centred care, despite the known constraints of hospital routine and structure.5,7 Similarly, McLachlan and colleagues found from the COSMOS RCT women’s experiences of caseload midwifery care to enhance their sense of control during labour and felt more positive about their childbirth experience (including the pain experienced).6 Not only has midwifery CoC afforded benefits to women, but also to the midwifery workforce. Australian and New Zealand midwives working in CoC are known to experience lower levels of burnout,8 anxiety and depression, compared to those working in standard models of care.9,10 In response, the midwifery education sector has also taken intentional steps to support this momentum. Over the past 20 years midwifery preparation for practice

programs have undergone substantial change. Since, 2010 a key training requirement is the Continuity of Care Experience (CCE); whereby students are required to ‘follow women through’ the perinatal period, including the pregnancy, birth and postnatal period.11 Arguably, this prepares students to work across the perinatal continuum and exposes them to the strengths of working in partnership with women.12 Despite this robust evidence base and national policy and strategic direction to implement and expand midwifery continuity of care services,13 women within Australia have limited access to midwifery continuity of care; with exact rates difficult to define. In 2015 a nationwide survey targeting women who had given birth in the past five years (n = 3123), identified that 19% of women selfidentified as being part of a continuity of midwifery care program.14 However, the most recent cross-sectional survey within the Australian context of service providers found that only 31% of respondents (midwifery managers in public hospitals) reported that their hospital offered caseload midwifery, with an estimated 8% of women (predominantly ‘obstetric low risk’) having access to this model. Whilst only 63% of eligible participants responded, it is the most comprehensive data to date. Barriers identified to expand or implement midwifery continuity of care were establishment funding, availability of midwifery staff and lack of strong support for the innovation.15 It is now 16 years since the National Maternity Action Plan called on federal and state governments to facilitate women’s access to a known midwife throughout the perinatal continuum,16 and despite some improvements in access to this model of care, much work remains. As Homer17 so clearly stated, “Changing the way midwives work so that they can develop meaningful relationships with woman seems simple on one level. Changing the system so that women’s needs, rather than the needs of the institution . . . is crucial” (p.80). System change is required, yet little literature has detailed the actualisation of this in the context of upscaling midwifery CoC. Therefore, the purpose of this study was to follow the journey of one hospital and health service in coastal Queensland, Australia through the introduction and subsequent upscaling of midwifery CoC. The maternity service’s leadership (Clinical and Service group directors) embraced the construction and subsequent relocation to a new hospital as a unique opportunity to redesign and restructure services to implement and expand midwifery CoC. Initially, CoC consisted of two groups, with each containing 2.0 full-time equivalent midwifery positions (shared by 3–4 midwives working 0.5–0.75 FTE), and was deemed an ‘all-risk’ model. The implementation was overseen by a project officer with experience implementing a midwifery CoC model interstate. Midwives were predominantly recruited from an internal pool of applicants. Currently, the CoC model within the health service has 6 teams with 12 FTE of midwifery staff and remains an ‘all-risk’ model. 2. Methods 2.1. Aim This study aimed to explore the perceptions and experiences of midwifery and obstetric medical staff during the implementation and upscaling of midwifery CoC within a regional hospital and health service in coastal Queensland, Australia. 2.2. Research design This study employed a qualitative approach. Qualitative research facilitates an in-depth exploration of experiences, underlying attitudes and perceptions according to participants.18 This was the most suitable design, as the purpose of this study was

Please cite this article in press as: C. Styles, et al., Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.008

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to explore and understand, from a maternity health professionals’ point of view, the impact of CoC on the whole health service; as part of a re-design initiative. Involvement of key stakeholders in change-process as participants is essential in ensuring engagement19 and facilitates organisational change by exposing underlying beliefs and their experience of the change. The context of the study was a regional hospital in Australia where approximately 2800 births per year were conducted. 2.3. Data collection Obstetricians and midwives were purposefully sampled according to professional group and model of care where they currently worked (core or CoC). They were invited to attend a focus group or individual interview, determined by participant preference and availability. Two rounds of data collection were undertaken: (1) within the first 2–3 months of CoC implementation, and (2) 2 years after implementation (see Table 1). The twoyear interval was to allow for establishment of the CoC service and the relocation of the entire maternity service to another hospital, which also occurred during this time. A semi-structured interview guide was developed and questions such as “What impact do you think the Continuity of Care service has had on service delivery?”, and “How has this model of care (CoC) affected your role as an obstetrician within the Hospital and Health Service?”. Data were collected by an experienced research midwife, who did not currently work clinically with the participants, but had experience in qualitative data collection methods. She had a good understanding of the topic area and could draw out dialogue on key themes arising at the time of data collection. Data were audio-recorded and transcribed verbatim. Transcription was undertaken external to the research team and transcripts returned with names and identifying information removed to protect participant confidentiality. 2.4. Data analysis Data were analysed thematically, consistent with the steps described in Braun and Clarke’s approach.20 The transcripts were read and re-read and themes and categories developed, with NVivo used to support data management and organisation. A range of strategies were adopted by the research team to enhance the rigour of this study. A robust review of research design and data analysis by authors two and three21 was undertaken. Frequent debriefing sessions involving author two and three were also held to discuss independent development of themes to test the ideas and interpretations and recognise individual bias and preferences. Incorporating the correct operational measures for the concepts being studied has been recognised as an important strategy to enhance credibility.21 For example; the line of questioning pursued

in both pre and post implementation data collection was specifically aligned with the aim of exploring the perceptions and experiences of participants. The investigation team also developed early familiarity of the participating organisation prior to first data collection. This enhanced the development of trust and engagement of participants with the research project. Another way that promotes credibility in the form of triangulation involves the use of a wide range of informants21 This study included caseload and core midwives and obstetricians which facilitated the verification of viewpoints and experiences and construct a rich picture of the phenomena of interest. Member checking22 of key findings generated from the study with participants was also undertaken. Dependability has been addressed by reporting in detail the processes within the study enabling future researchers to repeat the study. Transferability lies in demonstrating that the results of the work at hand can be applied to a wider population.21. The context of this study has been clearly described and organisation characteristics identified. 2.5. Ethical considerations This study was granted ethical approval [HREC/16/QPCH/16] and the study was conducted in accordance with the National Health and Medical Research Council’s guidelines for human research.23 3. Findings Four key themes and several categories were generated from the data. The four key themes were: hopes and expectations; clinical and practice changes; organisational and structural change; and, future directions (see Table 1). Data from both data collection points (implementation and after establishment) are presented together, in order to compare and explore consistencies and differences within participant perceptions during the maternity redesign process. Participant names have been replaced with abbreviations: MW (core midwives), CoC MW (midwives working in continuity of care) and OBS for obstetrician participants (Table 2). 3.1. Hopes and expectations 3.1.1. Supported by evidence At the commencement of the CoC service, unanimous agreement was voiced by both midwives and obstetricians regarding the strong evidence base and high maternal satisfaction levels known to be associated with CoC. The individualised care component was acknowledged, and all participant groups believed the model would improve clinical outcomes for both mother and baby across the continuum.

Table 1 Themes and categories. Theme

Category

Hopes and expectations

           

Clinical and practice changes Organisational and structural change

Future directions

3

Supported by evidence Acknowledgement of maternal satisfaction Improved clinical outcomes How CoC has contributed to women’s care How working in CoC affected my midwifery practice Re-organisation of maternity services — was it worth the effort? Employment level Contracted hours Leave replacement We are worried about ‘them’ but are ‘they’ worried? Consultation and referral Supply and demand

Please cite this article in press as: C. Styles, et al., Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.008

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Table 2 Participants. Participant group

During early implementation (n = 21)

After service establishment (n = 22)

Obstetricians

5 individual interviews (n = 5)

CoC midwifery staff

1 focus group (n = 4) 2 individual interviews (n = 2) 1 individual interview (n = 1)

Core midwifery staff

4 focus groups (n = 4; n = 6; n = 2; n = 2)

. . . the evidence is pretty clear that it's much better for women and I think the women that are seen in that model of care like it. They value it. (OBS 4B) 3.1.2. Acknowledgement of maternal satisfaction The CoC model was initially set up as a group of three midwives per group, with a primary midwife being allocated to each woman. This was to enhance relationship development, teamwork and consistency of information for the woman. Consistency of information was strongly identified as an important component linked to maternal satisfaction. There was a general consensus that even if the mother had only met the midwife attending her birth once, it would be better than having an unknown caregiver present for the birth. The women do meet the backup midwives during the pregnancy. So it's a maximum of three midwives that they are seeing (Senior CoC MW) I have a hope it will improve outcomes, particularly with better support. A more consistent message from a small group of people who will hopefully be consistently providing information and feedback . . . expectations around women during pregnancy and delivery and afterwards (OBS 2) 3.1.3. Improved clinical outcomes During the implementation phase, there was also an expectation that the introduction of CoC may improve outcomes for women, such as vulnerable population groups or women with mental illness. Specific outcomes which have been seen by the team to have improved over the two-year period are breastfeeding support and promotion of the whole family unit. Midwives felt strongly about the flexibility in providing additional postnatal support within the first two weeks post birth in comparison to the current model of care. It was very important that if the health service was going to commit to this organisational restructure it had to be worth the effort and demonstrate improved outcomes, as the perception was that the current service was performing well in regard to benchmarking with other similar health services. Breastfeeding . . . we can go out to them a lot more than the hospital midwives . . . if they're struggling with their breastfeeding, go out to them every second day and we can help them out, put plans in place (CoC MW4) I think we do a lot more to promote the family unit. You talk about it antenatally, but also postnatally it's bringing them in, involving them at that stage (CoC MW5) . . . if we're going to introduce it, we have to know that it's better than what we're currently doing. I think it's stupid to break up what has been a very functional system. I think in the last few years we've had a very good system of care here. I think the outcomes of care are really good. (Obs 2) 3.2. Clinical and practice changes 3.2.1. How CoC has contributed to women’s care Many participants reflected upon the CoC midwives’ passion and investment in the women they cared for. Women’s individual

2 focus groups (n = 5; n = 2) 2 individual interviews (n = 2) 2 focus groups (n = 3; n = 5)

expectations and birth plans were clearly known, as were the woman’s history and story. CoC midwives highlighted how this relationship contributed to their confidence in developing an individualised plan of care and ability to inform and advocate as options were presented. The relationship also had anecdotally increased women’s compliance with recommended care and attendance at medical appointments. Promotion of normal birth was highly valued by the whole maternity team within the study site and the introduction of CoC was a positive move toward achieving and maintaining a service in line with the midwifery philosophy promoting normal physiology. . . . once they are going to . . . MGP [CoC] they definitely increase in compliance in certain things. Even in attending medical care. Because sometimes . . . for instance young mothers, they're more confident and more comfortable in seeing the midwives. Because hospital sometimes is a bit of a no-no place (Obs 2) I've also seen a couple of women actually change their birth plan, mode of delivery, because of the [CoC midwife] . . . how they actually manage to cope with their anxiety regarding certain mode of delivery. That is actually a positive impact as well (Obs 5B) . . . was a lot of anxiety of, especially primips, as they get to term, to have the baby as soon as possible, whereas because we're seeing them and reassuring them that the pregnancy will proceed normally, then they tend to wait longer before they induce (CoC RM2)

3.2.2. How working in CoC affected my midwifery practice Many of the midwives who had recently commenced in the CoC service within the study site were new to working within this model. They reflected on the positive changes this had when compared with working in core staff. These included; autonomy in structuring their work life, perceived impact on clinical interactions and the ability to manage distress and disenchantment of their women when birth or care had not met expectations or was identified as traumatic . . . . . . You don't bring them into the hospital until they're well established, because you know their home situation, you know who's with them, you know what their plans are around their birth, you've got so much bigger an idea of who they are before you come (CoC RM 2) . . . bad or is traumatic or whatever it is, you sort of take that on board more than you would before, and plus, seeing them at home afterwards, because when you were just birth suite, we never had that . . . we've got one woman who we've seen postnatally, who had a pretty traumatic birth, but in the two weeks she's actually she's actually come around because you've had that . . . ongoing debrief. She's feeling so much better (CoC RM8) One of the processes which was identified as problematic in the early months after implementation was the CoC midwives learning to develop clear professional boundaries and expectations between themselves and their clients. The ability for the CoC midwives to meet regularly, discuss issues and develop processes to manage them was important. The core and CoC midwives also reflected upon this, and experience had informed setting up clearer expectations for the staff as they mature into the CoC roles.

Please cite this article in press as: C. Styles, et al., Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.008

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One of the things I notice is that because people are in the MGP [CoC] group they believe that they can contact their midwives at any time with any trivial issues. Yes, there's a contact point. . . . a midwife who told me that she has received texts every hour at night-time . . . that's definitely quite disrupting. (Obs5) I was talking to [service director] one day and talking about that not very good at switching off, not very good at letting stuff go, and she said do you turn your phone off when you're on your days off? I was like no, I leave it, I check messages. She's like that needs to be your New Year's resolution. You need to not check your phone. These are grown women. They will call. (CoC MW8)

3.3. Organisational and structural change 3.3.1. Re-organisation of maternity services — was it worth the effort? Organisational change involves multiple factors and considerations, especially when large complex health systems are involved. The participants agreed that the significant effort involved in introducing and then upscaling CoC was worth the effort, because of the potential benefits it afforded women. . . . when you look at some of the women who are likely to be seen in the MGP [CoC], women with anxiety and psychological or psychosocial problems, they will certainly benefit from better continuity of care, and there is some evidence, particularly around anxiety, that increased levels of anxiety impact on outcomes during pregnancy and in labour . . . If they can be mitigated by better continuity of care (Obs1). It was important to offer an ‘all risk’ model of CoC to cater for women with increased vulnerabilities, such as teenage mothers and women identifying as Aboriginal and/or Torres Strait Islander. This was aimed at improving their health outcomes through pregnancy, birth and early parenting experience. The recognition of previous trajectories for these women was noted and the inclusion was valued. If women were initially ‘low risk’ (category A24) and then developed complications during their pregnancy, they were also eligible to stay with the CoC service. Fiscal implications of multiple doctor and midwife visits were discussed. Piloting of a ‘midwife navigator’ role for the women to have a level of continuity when they are under obstetric care was suggested, specifically for the many women who do not receive CoC care due to various reasons. The other thing I think that is really interesting since MGP [CoC] came on board is that we're seeing the Indigenous women earlier. Their booking in is a lot earlier. They're obviously more comfortable with this model (Senior Core MW) . . . because MGP's [CoC] popular, one of the issues we have is if we've got a woman who's got high needs . . . we don't have any provision for having a midwife navigator or a nurse navigator to go with the woman and walk her through all - for complex care (Obs 4). The role and scope of care provision for the CoC midwives was identified as a topic for further discussion and deliberation when women met specific criteria classifying them as ‘at risk.’ Midwives attending the additional specialist appointments found them to be an important avenue to support their known woman. In the early phase after implementation, participants voiced that they went along to obstetric appointments with women, however this became problematic in terms of workload and duplication of service. The impact of a ‘new’ service on financial resources was also discussed substantially amongst the obstetricians, and that this investment would be expected to yield improvements. Once CoC had been established over a two-year period, this feedback was taken on and new systems have been implemented to avoid duplication and improve information sharing.

5

. . . certainly with really complex patients that a midwife comes to a doctor antenatal clinic appointment would seem reasonable. So they have a good idea of the plan going forward and can be a coordinator . . . but we do have instances where one or even two midwives come to a fairly straightforward appointment which would seem to - you know, when you have two people being paid to do what we usually do as one person, and occasionally come into postnatal appointments and things like that, seems to be a little bit of a waste of time in my opinion (Obs2) Don’t you think continuity of care is important? Of course we think it's important, but it's also important that we provide an equitable service and spend the money that we get allocated in the best possible way (Obs 4) Midwives in the CoC model felt the personal connection and ability to visit women in their own home when labour signs were evident reduced maternal stress by providing a plan of care based on clinical assessment. Cost savings were thought to occur from the CoC midwives’ perspective in terms of hospital avoidance and shorter length of postnatal stay. However, this was anecdotal information, and not measured as part of this study. . . . there is less antenatal presentations of the women, because they can ring us and talk to us and because we know their history, we wouldn't necessarily bring them into the hospital if they've got a problem . . . so there's less antenatal presentations (MGP RM 1) The loss of experienced staff from any specialty clinical setting has the potential to trigger concern and anxiety around patient safety and ability to provide responsive cares. This redesign occurred in a regional location which drew mostly on midwives currently working in the core teams to move across to CoC. This had an unexpected (although not surprising) impact upon the workforce, especially within the birth suite. Probably the main concern has been the effects of experienced staff that have gone into Midwifery Group Practice but have moved out of the other areas (CoC senior MW) 3.3.2. Employment level How the CoC service is structured may be influenced by different facilities, client groups, client acuity and service capability. Decisions around employment levels and acknowledgement of the broad scope and expected level of functioning occurred during the planning stage. The decision resulted in a collaborative, team approach where the more experienced midwives work alongside the newer midwives, with opportunities for succession planning. Discussion amongst core and CoC staff centred around employment level and grades. I wouldn't like to make all the MGP [CoC] girls just be CNs (senior midwives) because it will close the door to a lot of younger midwives that are really motivated to do - to be involved in that sort of care. They can develop into CNs as the time goes (Core MW 5) I think it's a collaborative thing, they just need to be together. So, I don't think they need to be a CN to deliver MGP [CoC] care and MGP [CoC] model. As long as they've got that CN to report to, within a team - I think within their team they need a CN, for sure . . . (Core Senior MW2) It was agreed that this study site had a very well-resourced maternity service with excellent obstetric, neonatal and midwifery support which could be accessed around-the-clock as needed. Part of this involved the ability for the CoC service to offer an ‘all risk model’ as discussed earlier. The participants did not express strong views either ‘for’ or ‘against’ a low- or high-risk model, but rather the focus was about working toward the highest quality care for individual women being cared for by the service. There was however, solid consensus that women with mental illness or similar vulnerabilities, such as a

Please cite this article in press as: C. Styles, et al., Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.008

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previous traumatic birth, were prioritised to receive continuity of care. . . . obviously it's always beneficial to everyone, but especially for those women . . . [with] social issues, mental health, sexual abuse . . . They're not explaining that to everyone they meet and they're not having to keep going over their story. They're . . . high risk obviously - possibly not obstetrically . . . (MW MGP 2) 3.3.3. Contracted hours Variations exist within different continuity of care midwifery models regarding expectations of ‘full-time equivalent’ working hours, with some requiring full-time staff only and others facilitating various part-time arrangements. The structure of the model within this study site was flexible with many midwives choosing to work part-time. This worked well for work-life balance, however had some perceived limitations in the subsequent provision of real continuity for the women. Two 0.5? I don't think 0.5 can give continuity of care. That's my personal opinion. That's 20 hours a week that you are offering . . . (Core MW 6) . . . I think a little bit higher FTE would perhaps help the place run a bit better. I also think that in a team, they should all be the same, so all be working 0.8, not unevenly, because it probably puts more of a load on the person who's more here (CoC MW3) 3.3.4. Leave replacement It was identified that responsive processes are needed to be in place prior to commencement of the model to enable adequate coverage and care provision when the CoC midwives were on leave. How the CoC sick and annual leave was covered within the context of maintaining continuity for the women was also an area that took time to resolve. In the early stages of implementation this seemed to occur on an ad hoc basis and resulted in a lack of continuity for women. It was certainly identified as a limitation to the service. Strategies mentioned to address this were that each team included more full-time equivalent staff and that a procedure is in place so that women meet all members of the group practice during their pregnancy. The relieving is probably the biggest though and not knowing what's going to happen when you know you're coming up to going away on holiday and it's like I've got ladies that need care (CoC MW1) . . . a more FTE team, but also, I see a lot of people rushing off on annual leave, and somebody else comes in to join, and somebody else comes in, and someone's leaving, and someone's sick; there seems to be a really disjointed lot of people, and I don't think that can give good continuity to the woman (Core MW 8) 3.3.5. We are worried about ‘them’ but are ‘they’ worried? The core staff and obstetricians voiced concerns about the wellbeing of the CoC midwives, especially becoming exhausted and burning out. This was based on the premise that the midwives working in CoC invested heavily into their clients to the point of ‘loving them to death’ (BS CoreMW1). Of significant interest were the views of experienced obstetricians who had engaged in ‘oncall’ work for many years and they reflected on this considering the expanding ‘on-call’ nature of midwifery services. I am concerned about some of the MGP [CoC] staff. The senior ones in those teams . . . they look exhausted. Haggard, they drag their feet, and no one likes coming to night shift; whether that’s their time management skills, whether that’s the system, whether that’s not enough support from their NUM, I mean I don’t know? (Core MW 6)

The other concern that I have about the MGP [CoC] is the sustainability of it. Having worked in the private obstetric sector for a number of years it is pretty demanding being on call seven days a week. I know that . . . .But I can foresee that this is - this could be a problem and it's certainly been a problem in other MGPs [CoCs] that I'm aware of . . . (Obs 2) Whilst the CoC midwives acknowledged that there were some challenges associated with their new role they were able to identify and implement strategies to mitigate the impact. The CoC staff identified collegial support helped the maintain their wellbeing. They also highlighted the importance of support from their team and colleagues, and how they valued the autonomy in structuring their team according to their own needs. I think you have to run your team the best way works for you. I don't know if that's something we're allowed to do, and I think [service director] spoken to us before in regards to you have to work your team out to the best of your - that works for your team. If you want to come in for your women, come in; if you don't, you don't. But you all have to be on board (CoC MW 4) The opportunity to engage in external clinical supervision and mentorship was also offered as a strategy in the early implementation phase of CoC to support the midwives transitioning across from traditional core staff. However, the uptake of this was limited with the midwives preferring to debrief and seek support from their peers within the service. As far as the MGP midwives go, they have had that mentoring with both of the first year. Which some used well, some probably less so. I think they seek a lot of support from each other (MGP MW 3) The coming and going of midwifery staff from core to CoC raised some discussion on adequate orientation to working in different models of care. In the early stages of implementation, orientation to the CoC model was identified as lacking and inconsistent and this proved to cause some challenges. This was to be addressed through strong mentorship and opportunity to ‘upskill’ in various areas as need be. . . . a lot of birth suite midwives who are doing now postnatal care or haven't set foot into the postnatal ward for many, many years, not really knowing what they're doing . . . when you look at our purpose out here is to prepare this woman and her family, her partner for taking this baby home, if you're not doing it to the highest possible standard you possibly can, we can't guarantee we're giving her the best start (MW2) So that how do you get experience? Well time on the job; but you need support on the job. You need to be mentored through different things . . . when you're a junior midwife there . . . there'll be things that the - there are things you know you don't know. So that you need to have someone there to guide you through that (Obs 1)

3.3.6. Consultation and referral A significant point of discussion during the focus groups and interviews (both during phase one and two of data collection) was the communication both between midwifery staff and CoC midwives; and obstetric staff and CoC midwives. In the phase one interviews the midwifery staff from the core services discussed some confusion between their role and the CoC midwife role however, this seems to have been well resolved over time. Sometimes that work is still left up to us, and I think the challenges have been, potentially, that there's been no . . . clear guidelines about what their scope is, exactly, what they'll do when they come in, what they won't do . . . sometimes that depends on the midwife . . . (Core MW 10)

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This was mostly evident during the postnatal hospital stay where the confusion around roles lay. Suggestions were that the core staff could provide this care or the CoC midwife and these views differed with little consensus from participants. . . . there's just some midwives will come in, they'll do the bath, they'll do the Hep B, they'll do all of the discharge education, everything is done. Some will just come in and sign off the discharge education but the bath hasn't been done, the Hep B hasn't been done . . . (Core RM1) I see it a little bit unfair that the MGP midwife is expected to do a neo-natal screen, or a bath, or even post-natal discharge education, because I would think that the woman should just get everything from us. Then, if she gets a little bit of top-up at home, that's a bonus for her. But yeah, I was surprised that MGP came in to do thing . . . (Core MW2) An ‘us’ and ‘them’ culture was a factor which participants voiced as concerning and did not want to become a rift between the different parts of the service. Including the CoC service in handover, shared team meetings and ‘talking up’ each part of the whole maternity service to women were identified as key mechanisms to avoid this. When we first started, over the 12 months, there was a real us and them culture. I think it's improving, but it's still there, so we're really just another way, another way of - another part of the team (CoC MW1) . . . need core staff and they're fabulous. So I always sell up the core staff as well . . . because they're part of our team and they'll relieve us for meal breaks and . . . And once they get to the postnatal ward as well . . . they'll be needing core staff support (CoC MW 5) Regarding consultation and referral between CoC midwives and obstetricians the communication pathways have been more challenging. ‘Corridor conversations’ were discussed. They were not an appropriate method for consultation regarding more complex women. Suggestions were fielded to overcome this difficulty, including aligning an obstetrician with each CoC team and allocating obstetric clinic time for CoC consultation to occur. . . . is there some way of coordinating midwifery group practice with a group of obstetricians as well? So you can have - extend the team into the medical group as well. (CoC MW 3) . . . think it's a good idea that MGP [CoC] could be aligned with a consultant (Core MW1)

3.4. Future directions 3.4.1. Supply and demand Soon after CoC was introduced the waiting list started, and grew, and grew! The current service offers 20% of women CoC, however many women remain on the waiting list. It was agreed that women were reassured that if they were unable to get into CoC service that the core service was also of a high quality. This message was important for women to know. . . . clients that don't get in because there's not enough spaces only 20 per cent of our bookings. That's disappointing for them. So, whether or not we can do something with GPs early on in booking to clarify that, that it’s not an option for 100 per cent of our clients, because they are disappointed (Core MW 2) Upscaling of CoC whilst acknowledged to be essential, was recommended with caution as participants would like to see issues such as challenges with consultation and referral ‘ironed out’ before the CoC service grew. A stepwise approach to upscaling was recommended, whilst continual evaluation and quality

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improvement occurred simultaneously to ensure quality maternity care. I think it is a wonderful model of care. There are still quite a few things to iron out, a few things to process . . . I know that it's been talked about expanding it, but I think it's better just to leave it at the moment to improve it before we expand any further (Obs 2) So I think expanding it is probably a good idea, but is it cost effective? Can we afford it? Have we got the midwives to do it? We've got to be mindful of the provision of other services, the sort of core services for the women - our sickest women, yeah, the ones that I tend to care more for (Obs 3) Participant discussion regarding the implementation, change and upscaling of CoC within a public health service was seen positively with valuable feedback on the direct experiences of the whole maternity team voiced and considered. These findings provide a candid, insightful perspective from the multi-disciplinary team.

4. Discussion This study explored the views and experiences of the maternity team following the initial introduction of midwifery CoC and the impact it has had two years on. Prior knowledge and understanding of the strong evidence base and high maternal satisfaction levels contributed to the multi-disciplinary support found for this redesign. The evidence of the benefits of re-orientating maternity services to provide all women, regardless of risk, with a known caseload midwife within a supportive multidisciplinary team is now clear and compelling.2,25 Evidence to support the need to increase the implementation of continuity of care models from the both the M@NGO trial26 and COSMOS trial27 should give policy makers and health service funders’ confidence that the findings reflect positively on the clinical outcomes from the continuity of care models. The relationship between woman and midwife in CoC was believed to contribute positively to women’s care, with breastfeeding support and an increase in maternal engagement with services acknowledged. Research has highlighted how women who receive continuity of midwifery care report higher ratings of maternal satisfaction28 and are more positive and less anxious about their overall birth experience.6 In addition, women have identified greater satisfaction with the information, care and advice they receive regarding their preparation for labour and birth than women using other models of care.2,28 CoC was not only observed to be good for women, but also for midwives. Increased job satisfaction, improved flexibility in working arrangements and an enhanced sense of autonomy in the midwives’ professional role was highlighted in this study. The ability to develop a relationship and follow up with women was key to the level of satisfaction expressed. Previous research has identified when midwives are attempting to manage conflicting ideologies, resulting in an inability to provide woman centred care, feelings of frustration, anger and emotional exhaustion arise.29 Conversely, the ability of midwives to develop relationships with childbearing women has been identified as a motivator towards staying in the profession.30 Previous research has linked staff retention with job satisfaction levels, naming midwifery relationships, professional identity and the practice of midwifery as incentives to remain within the profession.31 Concerns about CoC midwife burnout and sustainability of the service were raised by staff members not working in this model or with previous exposure to ‘on call’ service provision. This notion has not been supported through earlier research examining factors contributing to midwives’ levels of burnout.8,32,33 These studies

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found strategies such as clinical mentorship (supervision) and reorganizing models of care to increase work satisfaction, autonomy and relationships with women were worthy of continued investigation when seeking to reduce burnout which consistent with the broader literature.8,34,35 Discourse pertaining to the structural and organisational elements of the introduction of CoC was a substantial theme of this study. Concerns such as the movement of experienced clinicians from areas such as birth suite, and staff not maintaining the relevant skills to practice autonomously across their full scope of practice. These issues were subsequently addressed through appropriate mentorship and opportunity to ‘upskill’ in various areas as required during orientation. The need to increase the skill of the midwifery workforce to achieve and sustain midwifery continuity of care models has been identified by policy makers and midwives.36,37 It has been identified that when an organisational framework that promotes job satisfaction exists the motivation for professional development is enhanced.38 Midwives perceive organisational factors to be important determinants affecting practice.39 Organisational factors such as employment level, contracted hours and leave replacement were identified and addressed throughout the implementation period. A pivotal mechanism to facilitate the implementation and enable ongoing success of this model was from within the midwifery management team. Midwifery managers were regularly consulted and engaged in addressing staffing challenges across the whole of service; also, a key contributor identified to enable upscaling. Structurally this re-orientation of services was difficult, yet with a whole of team ‘in-principal’ support, change was possible. Such leadership within systems, at all levels, can inform change to enhance midwife-led care and improve choice for childbearing women.40 Implementing and evaluating new models of care in health service provision is complex. A properly designed model that provides on-going management support, effective back up and cover flexibility has shown to be more sustainable. The evidence suggests the CoC midwifery model of care is safe and economically viable. For women at low-risk of birth complications, CoC has been shown to be cost effective,41 yet for women cared for in an ‘all-risk’ model of midwifery CoC, the literature is not so clear. Midwifery CoC is known to afford benefit in decreased likelihood of preterm birth,42 which could contribute to a reduction in healthcare costs overall; yet, this was not the focus of this study. A cost neutral impact has been suggested based on evidence from studies using an intention to treat analysis of midwife continuity of care models.43 The differences in cost stem from shorter hospital stays and the lower level of some tests and interventions.44 However, overall there is insufficient up-to-date information about the economic costs and benefits of continuity of care.45 A cost-effectiveness study which examines the full scope of maternity care along with long term follow up of outcomes for women and babies, would be highly valuable. Continuity of midwifery care from the perspective of obstetricians has not been explored, despite their significant involvement in working with midwives and critical role in caring for women during the perinatal period. To successfully re-orientate maternity services to upscale CoC it is important to respectfully and clearly communicate and collaborate with all members of the healthcare team. Poor intra and inter disciplinary communication and collaboration is a significant barrier to large scale implementation of caseload midwifery and this is a major predictor of dysfunction within organisations,46–48 Effective collaboration between providers of maternity of care assures interdependency, shared ownership of service goals and leads to improvement of organisational effectiveness.49 In this study site, the obstetricians were highly supportive of midwifery CoC which resulted in a positive environment for the upscaling of midwifery CoC. Interprofessional

collaboration is needed to work co-operatively to provide comprehensive, effective and safe care to women. 4.1. Strengths and limitations This study provides a unique insight into the experience and views of the multi-disciplinary maternity team when CoC is being newly introduced and subsequently embedded into a health care service. The purposeful collection of data from multiple informants (core and caseload midwives and obstetricians) improves the credibility of the findings when examining midwifery CoC introduction and upscaling. This study is context specific as it was of a qualitative nature and conducted in a single site, thus limiting the generalisability of the findings to the broader population. However, the findings remain important and may offer insight to other health services when considering introducing or upscaling CoC services. 5. Conclusion There is significant high-level policy support within Australia13 and internationally25 to provide caseload midwifery. Desirable features of successful implementation of Continuity of Care at this site included: effective planning, communication, collaboration, and teamwork (between midwifery management, obstetricians, core and caseload midwifery staff). Issues that arose could have been avoided if a clear implementation strategy was in place prior to commencement. Organisational ownership is needed to assist with tailoring the implementation to the local context to meet consumer needs. Clear aims, monitoring, evaluation and feedback should be built in alongside the implementation coupled with support and flexibility for those working in the model. Staff member feedback on organisational issues led to the streamlining of processes and opportunity to showcase lessons learnt. Findings identify how organisational culture, structural change, communication processes and collaborative relationships can be used to inform future upscaling and sustain midwifery caseload care. Ethical statement This research study was approved by The Prince Charles Hospital HREC committee [HREC/16/QPCH/16], on 12th January 2016. Funding None declared. Conflict of interest None declared. Author contributions All authors have contributed significantly to the article and agree with the article content. CS was involved in concept, design and review: LK was involved in design, data collection and analysis and manuscript preparation; KG was involved with data analysis and manuscript preparation. Acknowledgements This study was unfunded. The research team would like to thank and acknowledge the participants for their valuable contribution and willingness to participate in this study.

Please cite this article in press as: C. Styles, et al., Implementation and upscaling of midwifery continuity of care: The experience of midwives and obstetricians, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.08.008

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