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The Australian College of Midwives believes that it is the right of every pregnant woman to have access to continuity of care by a known midwife for her pregnancy, labour and early postnatal period. Midwives are the most appropriate primary care providers for healthy mothers and newborn babies and are able to refer to specialist medical care if the need arises (Hicks, Spurgeon & Barwell, 2003). Midwives must work within the competency standards enforced by The ANMC Australian Nursing & Midwifery Council (2006) in order to obtain and practice as a registered midwife in Australia.
Competency 4 states Midwives should “promote safe and effective practice” (ANMC, 2006), this is achievable by providing Midwifery continuity of care to women and there babies. Continuity of care has numerous health and satisfaction benefits to the woman, family and newborn (Lavender et al. 2002). Midwifery led care emerged in the UK in the early 1990s in response to government policy changes to maternity services and provisions (Carolan & Hodnett, 2007).
A variety of studies conducted in Australia and in the UK found that women giving birth at public hospitals were particularly unhappy. Issues raised included a lack of continuity of care, long waiting times in clinics, a lack of information and involvement in decision making and a lack of respect and sensitivity among caregivers (Carolan & Hodnett, 2007). In recent years the alternative care models have focussed on continuity of care, and particularly that provided by midwives, as a key concept in endeavours to increase women’s satisfaction with care (Waldenstrom & Turnbull, 1998).
According to the International College of Midwives (ICM), Continuity of midwifery care means a woman is able to develop a relationship with a midwife to work in partnership for the provision of her care during pregnancy, labour birth and the postnatal period. Whilst there are many ways in which midwifery care may be organised, midwives can function autonomously as primary care providers, and do so with the view to personalising care for each woman , providing referral to other health professionals if required (Spiby & Munro,2009).
Continuity of care may have different meanings, ranging from continuity of caregivers, to a shared philosophy of care by large numbers of caregivers with different professional backgrounds or ideally one-to-one care (Waldenstrom et al. 2000). The purpose of midwifery continuity of care is to allow women and their midwives to get to know each other over time. This involves not only a personal knowledge of each other, but also the ability to be able to work out, investigate, talk about and consider the complex decisions, bearing in mind the woman’s needs and expectations.
The relationship has a professional purpose, which is the provision of safe and effective midwifery care (Homer, Brodie & Leap, 2008). The ANMC states that midwives should promote safe and effective practice. This competency standard involves: Applying knowledge, skills and attitudes to enable woman centred care, provide or support midwifery continuity of care and manage the midwifery care of women and their babies. Midwives providing continuity of care are able to provide safe and effective practice.
They know there patients well from the woman’s blood test results to the woman’s birth plan. The midwife can provide safe and effective practice because she knows the woman best. Midwifery Continuity of care is associated with a reduction in the rate of a number of interventions, without compromising safety of care (Spiby & Munro, 2009). Continuity of care is known to decrease the need for pharmacological pain relief in labour while increasing breastfeeding rates and maternal satisfaction (Page et al. 999). Continuity of care is an effective primary health strategy enabling women to participate in decision making about their health and their health care. Mothers felt that they had significantly more choice over location of birth, type of maternity care, delivery and pain relief; they were also more satisfied with information provided about details of care, preparation for labour and pregnancy testing (Carolan & Hodnett, 2007).
Midwives are qualified to work in continuity of care models in a variety of settings, including public and private hospitals, community services, rural and remote health care and private practice. Australia is one of the few developed countries where access to a known midwife for the childbirth continuum remains uncommon with fewer than 5% of women having the choice of care by a known midwife throughout their maternity episode (ACM). Continuity of midwifery care has been shown to reduce interventions in labour, particularly augmentation of labour, analgesia use and electronic fetal monitoring (Homer et al. 001). A small Canadian trial in 200 women demonstrated a significant reduction in caesarean section rate and an Australian trial reported a trend towards a reduced elective caesarean section rate in high risk women (Homer et al. 2001). Page et al. (1999) noted a significant reduction in epidural analgesia, lower rates of episiotomies and perineal lacerations and a shorter second stage of labour with continuity of midwifery care. Conversely, Brown and Lumley (1998) reported from an Australian study, that there is the potential for both positive and negative effects on mother and baby.
It has been demonstrated that social support may reduce the duration of labour, and it would be reasonable to assume that continuity of midwifery care could have a similar effect by reducing anxiety associated with unknown caregivers. With regards to clinical outcomes, there is evidence that midwifery-led provision does not compromise safety of care or produce any increase in problems (Hicks, Spurgeon & Barwell, 2003). Women involved in Midwifery continuity of care strongly agreed that care was provided in a safe and competent way and they were happier with the physical aspects of care.
These findings may seem surprising, considering the more specialised training of doctors in diagnosing and treating medical problems during pregnancy. However in this study by Waldenstrom et al. 2000, women in standard care also saw resident doctors who were less experienced. The other important component in considering safety is that of perinatal outcomes. In Waldenstrom and Turnbulls 1998 study, the proportion of infants with an Apgar score