LTP Priority: Maternity
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Targeted and enhanced midwifery-led continuity of carer
Major driver of health inequalities in your area of work
Increased risk of perinatal mortality for babies of mothers from Black and Asian ethnic backgrounds and babies born to mothers living in the most deprived quintile LLSOAs
Women in deprived areas; Inclusion Heath groups – There is evidence that those who are homeless and rough sleepers, vulnerable migrants and from Gypsy, Roma and travelling communities are likely to experience poorer maternal and perinatal outcomes; and women from different ethnic groups based on race groups: Black; Black British; Asian; Asian British
Targeted and enhanced midwifery-led continuity of carer
The government’s ambition is, by 2025, to halve rates of stillbirths, neonatal and maternal deaths and brain injuries occurring during or soon after birth and to reduce preterm births from 8% to 6% (DHSC 2017). In order to achieve the government’s ambition and reduce health inequalities, it is important to target those groups in the population most at risk.
There are significant and widening health inequalities in maternity care. When compared to babies of White ethnicity: Black/Black British babies have a 121% increased risk for stillbirth and 50% increased risk for neonatal death and the gap has been widening since 2013; Asian/Asian British babies have a 66% increased risk of neonatal mortality and this risk is rising and an increased risk of stillbirth of around 55%. Babies born to mothers in the most deprived quintile have a 30% increased risk neonatal mortality and the gap between the most deprived and the least deprived quintiles is widening. Draper et al 2018.
The term ‘continuity of carer’ describes consistency in the midwife or clinical team that provides care for a woman and her baby throughout the three phases of her maternity journey: pregnancy, labour and the postnatal period (NHS England 2017). Women who receive midwifery-led continuity of carer are 16% less likely to lose their baby, 19% less likely to lose their baby before 24 weeks and 24% less likely to experience pre-term birth and report significantly improved experience of care across a range of measures (Sandall et al 2016). Pre-term birth is a key risk factor for neonatal mortality.
Continuity of carer can significantly improve outcomes for women from ethnic minorities and those living in deprived areas (Rayment-Jones et al 2015, Homer et al 2017 in RCM 2018).
The Marmot Review (2010) proposes a strategy to address the social determinants of health through six policy objectives; the highest priority objective being ‘giving every child the best start in life’. Marmot noted that in-utero environments affect adult health. Maternal health, including stress, diet, drug, alcohol and tobacco use during pregnancy, has significant influence on foetal and early brain development.
Midwives have a key role in promoting public health. Individual needs and concerns can be better addressed when midwives know the woman and her family – continuity of carer is a key enabler. This public health work is of most benefit to vulnerable and ‘at-risk’ families, who may require more time and tailored resources. Sanders et al 2015.
Continuity of carer is being implemented across England through the Maternity Transformation Programme. Implementation guidance (NHS England 2017) and a monitoring and evaluation framework (Sandall 2018) have been published. The NHS Standard Contract 2019/20 stipulates that 35% of women will be booked onto a continuity of carer pathway by March 2020. The NHS Planning Guidance 2019/20 (Appendix 1, p.35) sets out an expectation that that systems will to start to implement continuity of carer models for women of Black and Asian ethnic backgrounds and those living in the most deprived decile LLSOAs.
Additional work is required to address the needs of groups most at risk of poor outcomes. The Marmot (2010) review called for actions to be universal, but with a scale and intensity that is proportionate to the level of disadvantage. This is known as proportionate universalism. A targeted and enhanced approach to continuity of carer will give midwives: the opportunity (by targeting ‘at risk’ groups); and time to address modifiable risk factors with women who have complex social factors (in accordance with NICE CG110) and ensure close multi-professional working. Additional time for midwives to care for women with complex social factors can be created by investing in reduced caseload sizes, for example a 1:26 midwife to birth ratio for the most at risk women (which gives midwives an extra 11 hours per woman).
As well as improving clinical outcomes for mothers and babies, continuity of carer models also result in cost savings when compared to traditional models of care due to:
- fewer neonatal cot days (women are 24% less likely to experience pre-term birth)
- the incremental cost per preterm child surviving to 18 years compared with a term survivor. This is estimated at £22,885 (Mangham et al 2009). Most of these additional costs are likely to occur in the early years of a child’s life.
- fewer obstetric interventions (women are 10% less likely to have an instrumental birth)
- fewer epidurals (women are 15% less likely to have regional analgesia)
- DHSC (2017) New maternity strategy to reduce the number of stillbirths
- Draper ES, Gallimore ID, Kurinczuk JJ, Smith PW, Boby T, Smith LK, Manktelow BN, on behalf of the MBRRACE-UK Collaboration. MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births from January to December 2016. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester. 2018
- Mangham, L, Petrou, S, Doyle, L, Draper, E, and Marlow, N (2009) The childhood costs of preterm birth in England and Wales: A decision-analytic Markov modelling study. Paediatrics, 123(2):e312-27.
- Marmot, M et al (2010) Fair Society Healthy Lives (the Marmot Review)
- NHS England (2019) NHS Standard Contract 2019/20 General Conditions (Full Length)
- NHS England (2017) Implementing Better Births: Continuity of Carer
- NICE (2010) Clinical Guideline 110: Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors
- Royal College of Midwives (2018 a) Midwifery continuity of carer: an introduction [online]
- Sandall J (2018) Measuring Continuity of Carer: A monitoring and evaluation framework
- Sandall J, Soltani H, Gates S, Shennan A, Devane D (2016) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016 , Issue 4 . Art. No.: CD004667
- Sanders J, Hunter B, Warren L (2015) A wall of information? Exploring the public health component of maternity care in England. Midwifery.
Guidance for Commissioners
- Currently being developed.